


J^ 





LIBRARY Of^ CONGRESS. 

i^ 



^ 



C]iap._.\i_. Copyright No.. 
Sliell.T_b_5' 



UNITED STATES OF AMERICA. 



A HANDBOOK 



OF 



Genito-Urinary Surgery 



AND 



Venereal Diseases. 



BY 



GKM. PHILLIPS, M.D. 



Professor of Genito-Urinaiy Surgery and Venereal Diseases, Barnes Medical College; Chief of 

Genito-Urinary Clinic. Barnes. Dispensary; Visiting Clinician Genito-Urinary 

Department, St. Louis City Hospital; Member St. Louis Medical 

Society, Academy of Medical and Surgical Sciences, etc. 



Illustrated with half-tone cuts and special drawings by 

L. CRUSIUS. M.D. 

- /' 




TWO COPIES RECEIVED. 



>0«8 



COPYRIGHTED BY 

THE WESTERN ENGRAVING CO. 

ST. Louis, Mo. 



SHALLCROSS-McCALLUf/! CO. 

• . • -PRINTERS- • • • 

ST. LOUIS, MO. 



PREFACE 



This treatise, devoted to Genito-Urinary Surgery and Venereal 
Diseases, is ventured in appreciation of the needs of the Medical 
Practician and those Students of Medicine who feel themselves 
unable, on account of the cost, or unwilling, on account of time, to 
devote themselves to the larger and more exhaustive works upon 
such matters. 

The brevity of such a work must of necessity preclude the 
discussion of those subjects now undergoing adjustment at the 
hands of the profession. 

Therefore, the author (notwithstanding his indebtedness to 
Genito-Urinary workers generally, and his keen sense of appre- 
ciation of the views of others), for the most part, offers to his 
readers that which in his judgment seems best. 

To be practical, and present all matters in their most com- 
prehensive manner, has been aimed. 

The illustrations here produced are new, many being hand 
drawings by the celebrated histologist and artist, L. Crusius, M.D., 
(deceased). Such subjects have been selected for representation 
with that character of execution as best elucidate the text. 

It may appear that undue attention has been given the Anatomy 
and Physiology of these areas, the explanation being, that a cor- 
rect and thorough understanding of such subjects cannot be had 
without this information. The author acknowledges his in- 
debtedness to the firm of Blees-Moore Instrument Co., of this 
city, for the many cuts of instruments placed at his disposal; 
also the publishers, for hurrying the copy on to completion. 



CONTENTS. 



GENITO- URINARY SURGERY AND VENEREAL DISEASES. 



CHAPTER I. 

AXATOMY AND PHYSIOLOGY. PAGE 

Anatomy and physiology of the genito- urinary organizations 9 

CHAPTER II. 

DEFORMITIES, ETC. 

Deformities of the penis — Traumatic affections of the penis — Cutaneous 
affections of the penis — Tumors of the penis — Lymphatic affections 
of the penis — Phimosis — Paraphimosis — Herpes progenitalis — Ve- 
nereal Warts — Balanitis — Posthitis — Ossification of the penis — 
Calcification of the penis — Hypospadias — Epispadias — Circumcision 
— Amputation of the penis 34 

CHAPTER III. 

URETHRAL CURVE AND IRREGULARITIES. 

Proper curve of the urethra — Proper curve of urethral instruments — Im- 
perforation and atresia of the urethra — Catheterism — Hermaphrod- 
ism— Urinary fever — Hygiene of the urinary and sexual organizations 
— Foreign bodies in the urethra :... 58 

CHAPTER IV. 

URETHRAL EXAMINATION AND DISEASES. 

Urethroscopy or endoscopy — Diseases of the urethra — Inflammation of 
the urethra — Simple urethritis — Bastard gonorrhoea — Syphilitic 
urethritis — Tubercular urethritis— Gonorrhoea] urethritis — Anterior 
Gonorrhoea — Posterior gonorrhoea — Urethral irrigation and injection 
— Gleet — Relapsing gonorrhoea 7G 

CHAPTER V. 

COMPLICATIONS OF GONORRHCEA. 

Post-gonorrhceal neurosis — Lymphangitis — Adenitis — Abscesses of the 
urethral follicles — Peri-urethral inflammation — Cowperitis — Prosta- 
titis — Seminal vesiculitis — Epididymitis — Orchitis — Epididym- 
orchitis — Deferentititis — Cystitis — Urethritis — Pyelitis — Gonorrhoeal 
Conjunctivitis — Gonorrhoeal rheumatism 107 

CHAPTER VI. 

DISEASES OF THE PROSTATE. 

General consideration — Follicular prostatitis — Parenchymatous prosta- 
titis — Tuberculosis of the prostate — Malignant disease of the prostate 
— Prostatic stones — Atrophy of the prostate— Hypertrophy of the 
prostate 142 



CHAPTEE \-ll. 

CHANCROID. TAGE 

Definition — Incubation — Element in — Clinic features of — Frequency — 

Diagnosis — Prognosis — Complications — Treatment.. 166 

CHAPTER VIII. 

DISEASES OF THE KIDNEY. 

Pyelitis — Hydronephrosis — Kidney-stone Cancer — Pyonephrosis — Tuber- 
culosis—Syphilis — Floating kidney — Perinephritic abscess — Tumors 
— Nephrorraphy — Nephrectomy — Nephrotomy .- 175 

CHAPTER IX. 

STRICTURE OF THE URETHRA. 

Definition — Varieties — Causes — Pathology — Diagnosis — Treatment — 

Complications 183 

CHAPTER X. 

STONE IN THE BLADDER. 

Stone in the bladder — Definition — Causes — Symptoms — Diagnosis — 

Treatment 214 

CHAPTER XI. 

DISTURBANCES OF URINATION. 

Disturbances of urination — Physiology of urination — Urgent urination — 
Difficult urination — Involuntary urination — Retention of urine — 
Haematuria— Pneumaturia — Normal constituents of urine — Urinary 
examination 231 

CHAPTER XII. 

TUMORS IN THE SCROTUM. 

Hydrocele — Varicocele — Hsematocele — Spermatocele — Tumors of the tes- 
ticle — Stone ache — Neuralgia of the testicle 249 

CHAPTER XIII. 

IRREGULARITIES OF TESTES. 

Cryptorchidism — Monorchidism — Supernumerary testicles — Injuries of 
the testicles — Tuberculosis, syphilis and malignant disease of the 
testicles — Castration 267 

CHAPTER XIV. 

SEXUAL DISTURBANCES. 

Physiology of erection — Impotence — Sterility — Masturbation — Nocturnal 
and diurnal pollutions — Spermatorrhoea — Inversion and perversion 
of the sexual fancy — Neurasthenia sexualis — Sexual impulse — 
Sexual infelicity — Methods of the quack , 274 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Genito -urinary dissectiou. By D. A. Pelton, M.D ". 10 

2. Penis, bladder, urethra, prostate and seminal vesicles 12 

3. Cross section of the penis 14 

4. Dissection of the testicles 21 

5. Dissection of the kidney 28 

6. Malphigian corpuscle 30 

7. Section of kidney 32 

8. Double penis 35 

9. Paraphimosis 41 

10. Eeduction of paraphimosis 41 

11. Venereal warts 45 

11. Application of author's circumcision forceps 51 

12. Second step in circumcision operation 52 

13. Third step in circumcision operation 53 

14. Circumcision operation complete 54 

15. Curve for urethral instruments 59 

16. First position in the introduction of sound 61 

17. Second position in the introduction of sound 62 

18. Third position in the introduction of sound :. 63 

19. Fourth position in. the introduction of sound 63 

20. Pauline S., hermaphrodite 65 

21. Hermaphrodite ? 68 

22. Mathieus' urethral forceps 74 

23. Koltz's urethral endoscope 76 

24. Otis' urethral endoscope 76 

25. Brown's urethral speculum 77 

26. Leiter's pan electroscope 77 

27. _JEyo urethroscope 78 

28. Gonococci 83 

29. Weir's meatosbope 90 

30. Irrigation of the urethra 91 

31. Soft rubber urethral syringe 92 

32. Hard rubber urethral syringe, soft rubber tip 92 

33. Hard rubber urethral syringe, blunt tip 92 

34. Keif er nozzle 98 

35. Mitchell's soft rubber retrojector 98 

36. Cupped sound 99 



ILIvXJSTRAXIOT^S. 

FiCr, Page 

37c Lewis' ointment applicator 99 

38. Keyes' deep urethral syringe 99 

39. Lymphangitis complicating gonorrhoea 108 

40. Abscess in the lymphatic vessels 109 

41. Epididymitis and lymphangitis 116 

42. White's scrotal compressor 124 

42. Hypertrophy of the prostate 152 

43. Bougie a' boule linen 156 

44. Nelaton catheter 156 

45. Mercier's catheters 158 

46. Gross' improved catheters 159 

47. Chancroids, indurated from use of chloride of zinc 168 

48. Phagedenic chancroids 169 

49. Organic strictures of the urethra 185 

50. Scale for sounds 186 

51. Gangrene, following rupture of the urethra 192 

52. Otis' bulbous sound 194 

53. Conical steel sound ; 194 

54. Otis' urethrameter 195 

55. Whalebone filiform bougies 195 

56. Gouley's tunnelled catheter 195 

57. Tunnelled catheter and guide 195 

58. Gouley's tunnelled sound and guide 196 

59. Deep urethral syringe 196 

60. Piffard's meatometer 196 

61. Gouley's dilator 201 

62. Wyeth's modification of Otis' urethrotome 206 

63. Gouley's dilating urethrotome 206 

64. Gross' curved urethrotome 206 

65. Mason's catheter staff 208 

66. Lithotomy position 208 

67. Arnott's grooved director 211 

68. Gouley's beaked bistoury 211 

69. Teale's probe-pointed gorget 211 

70. Wheelhouse's urethrotomy staff 212 

71. Walker's knife 213 

72. Thompson's stone searcher 218 

73. Cystoscope, Nitze-Leiter r 219 

74. Lithotrite, Bigelow's , 223 

75. Evacuator and tubes, Bigelow's 224 

76. Lithotomy position 226 

77. Lithotomy staff. Little's 226 

78. Lithotomy knife, Blizzard's 228 

79. Lithotomy forceps, straight 228 

80. Lithotomy forceps, curved 228 

81. Malphigian corpuscle 231 

82. Cabinet for urine analysis 243 



ILLUSTRATIONS. 

Fig. Page 

83. Centrifuge, Queen & Co 244 

84. Saecharometer, Einhorn's 247 

8o. Hydrocele 250 

86. Hydrocele 251 

87. Varicocele 257 

88. Varicocele 259 

89. Scrotal clamp, Henry's ., 264 

90. Spermatozoa 268 

91. Psychrophor 281 



GENITO-URINARY SURGERY 

AND • 

VENEREAL DISEASES. 



CHAPTEE I. 

ANATOMY AND PHYSIOLOGY OF THE GENITO-URINAEY SYSTEM. 

The male organs of Generation are : 

1st. The Penis in all its parts. 

2nd. The Prostate Gland. 

3rd. The Testes with their appendages. 

The Urinary organs are : 

1st. The Urethra. 

2nd. The Bladder. 

3rd. The Ureters. 

4th. The Kidneys. 

The Genito-Urinary system then embraces all of 
the above named parts. (Pig. 1.) 

THE PENIS 

Is the male procreating organ, with a convenient but 
secondary urinary function ; its length and circum- 
ference, when flaccid, measure about three inches ; 
when erect, about double ; great variations in size are 



k 



10 



GENITO-URINARY SURGERY AND VENEREAL DISEASEvS. 



met ; the relationship that organs usually bear to physi- 
cal development at times is lost, for it is by no means 



Fig. 1. 




Genito-Urinary Dissection, by D. A. Pelton, M.D., winning the 
Phillips Gold Medal, 1897. 

unusual to see an individual of extraordinary size with 
an insignificant penis, or the opposite. This member 



ANATOMY AND PHYSIOLOGY. H 

is made up of a body (Plate 2, Fig. 1, IN'os. 8 and 9), 
a root (Plate 2, Fig. 2, 'No, 9), and an anterior ex- 
tremity, the glans-penis (Plate 2, Fig. 1, No. 11); 
it essentially consists of three bodies composed of 
erectile tissue, arranged to resemble the double barrels 
of a gun with ram-rod in place. ( See Fig. 3.) Con- 
spicuous in the volume of the penis are the two 
Corpora Cavernosa (Plate 2, Fig. 1, No. 9), arising 
by horn-shaped extremities, attached to the rami 
of the pubes and anterior surface of the respective 
tuberosities of the ischii ; their posterior fourths thus 
separated approach each other, making the anterior 
three -fourths intimately related ; interposed is an incom- 
plete fibro-elastic septum perforated liberally to admit 
of vascular communication, thereby insuring equal 
admission of blood, rendering erection of the organ 
symmetrical. The anterior termination of these bodies 
is in a blunt conical extremity, upon which rests the 

glans-penis. 

The Corpus Spongiosum 

(Plate 2, Fig. 1, ^o. 8) is smaller than the corpora 
cavernosa ; it occupies the under sulcus made by the 
apposition of these two bodies ; it has its posterior 
beginning in a dilated or bulbous portion situated at 
the angle made by the convergent corpora cavernosa ; 
this part is in relation with the anterior layers of the 
triangular ligament. The central portion of the corpus 
spongiosum is tunneled by the urethra ; its anterior 
termination is the glans-penis. 

The Glans=Penis, or the Head of the Penis 

(Plate 2, Fig. 1, iSTo. 11), resting upon the anterior 
<3onical extremities of the corpora cavernosa, as we 
have seen, resembles in shape an acorn flattened from 



12 



GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

Plate 2. 




Fig. 1. 
Drawn for and under the 
FlGL^RE 1. 
No. 1. Ureters. 
No. 2. Fundus of Bladder, 
No. 3. Base of Bladder. 
No. 4. Vas Deferens. 
No. 5, Seminal Vesicles. 
No, 6, Prostate Gland. 
No. 7. Cowper's Grlands. 
No. 8. Bulbous Portion of Spongy 

Urethra. 
No. 9, Corpora Cavernosa. 
No. 10. Frjeuum Prseputii. 
No. 11. Glans-Penis. 
No. A. Prostatic Urethra. 
No, B. Membranous Urethra. 
No. C. Spongy Urethra. 



Fig. 2. 
direction of the author. 

- Figure 2 
1 



No. 
No. 2. 
No. 3. 
No. 4. 
No. 5. 
No. 6. 
No. 7. 
No. 8. 
No, 9. 
No. 10. 
No. 11. 
No. 12. 
No. 13. 
No. 14. 
No. 15. 
No. 16. 



Ureters. 

Fundus of Bladder. 

L^retral Openings. 

Trigonum Vesicae. 

Veru Montanum, 

Sinus Pocularis. 

Prostate Gland. 

Prostatic Sinuses. 

Cms of Corpus Cavernosum. 

Diicts of Cowper's Glands. 

Fibrous Fascia. 

Corpus Cavernosum. 

Integument. 

Urethral Follicles. 

Fossa Navieularis. 

Lacuna Magna. 



ANATOMY AND PHYSIOLOGY. 13 

l^elow. Upon the under surface of the apex appears 
a slit-like opening called the Meatus Urinarius. The 
posterior raised border (as shown in Plate 2, Fig. 2) 
is called the Corona Glandis, and that constricted por- 
tion immediately behind the corona is called the !N^eck. 

The glans-penis is covered with a semi-mucous mem- 
brane in which abound nerves of sexual excitability ; 
also those glands, called Glandules Odoriferae, or the 
Sebaceous Glands of Tyson, whose function it is to se- 
crete that offensive cheesy material usually observed 
upon the person of the uncleanly ; the epithelium here 
found is quite fine. 

These three bodies are enveloped individually with a 
fibro-elastic covering of great strength (Fig. 3, jS'os. 
3 and 8) , and further surrounded by a common cov- 
ering of like kind, called Buck's Fascia. This latter 
-arises by a triangular bundle of fibres from the linea 
alba and symphysis pubis, which part is called the Sus- 
pensory Ligament of the penis. This tissue spreads 
over the corpora cavernosa, even to covering their an- 
terior extremities, where it divides into halves, which 
pass backward, covering the corpus spongiosum and 
blending with the deep layers of the superficial fascia 
of the perineum. This fascia is of considerable im- 
port, in that it limits infiltrated urine and protects the 
deeper structures of the penis against invasion of local 
infectious agents. Upon this fascia is found a loose 
connective tissue without fat, and over this the skin, 
which differs from skin elsewhere by taking on a pig- 
ment at the approach of puberty; the under surface 
of the skin here is marked by a raphe, continuous with 
that of the scrotum and perineum ; the anterior pro- 
longation of this skin, covering partially or completely 
the glans-penis, is lined with se]m-mucous membrane, 



14 



GENITO-URINARY SURGERY AND VENEREAL DISEASES. 



and is called the Prepuce ; attached to the inferior angle 
of the meatus urinarius, passing downward, backward 
and blending with the lower inner surface of the pre- 
puce is a fold of mucous membrane, dense and elastic, 
called the Fr^num Praeputii. (Plate 2, Fig. 1, 
:^ro. 10.) 

The Arteries 

(Fig. 3, No, 5) of the penis are branches of the 
internal pudics, one going to the bulb of the urethra, 



one 



each 



cavernosa. 




branches 



Cross Section of Penis. 
Drawn for and under the Direction of the Author by Dr. L. CruciiTS. 



No. 1. 


Superficial Vessels and Nerves. 


No. 7. Corpus CavernosiTm. 




No. 2. 


Skin and Fascia- 


No. 8. Fibrous Tunic of Corpus 


Spongio- 


No. 3. 


Fibrous Tunic. 


sum. 




No. 4. 


Corpus Cavernosum. 


No. 9. Urethra. 




No. 5. 


Deep Vessels. 


No. 10. Corpus Spongiosum. 





No. 6. Fibrous Septum. 

respectively to the glans-penis, prepuce and skin. 
The plexus of veins here found return the blood 
into the dorsal, thence into the prostatic plexus and 
pudendal veins. The nerves are derived from the 
internal pudics, with sympathetic branches, from the 



ANATOMY AND PHYSIOLOGY. 15 

hypogastric plexus. The lymphatic vessels are abund- 
ant and arranged in a superficial group communicat- 
ing with the lymphatic glands situated along and 
above Poupart's ligament, and a deep group terminat- 
ing in the ^^elvic lymphatic glands. 

The Urethra 

(Plate 2, Fig. 2) is a collapsed canal when not in use, 
limited in front by the meatus urinarius, and behind 
by the neck of the bladder ; its length is from seven 
and one-half to nine inches ; it is not of uniform cal- 
ibre, but presents points of physiologic deviation ; 
its average diameter, however, is slightly in excess of 
three-tenths of an inch. 

When the penis is erect, it offers but a single curve ; 
when flaccid, a doubfe curve is presented. That por- 
tion of the urethra contained within the substance of 
the corpus spongiosum is called the Spongy or Pendu- 
lous Urethra (Plate 2, Fig. 1, C) ; it is distinctly the 
longest portion, measuring about ^ye and one-half to 
six and one-half inches, the anterior portion of which 
presents a pouched or dilated appearance, which cav- 
ity, from its resemblauce to a boat, is called the Fossa 
^Navicularis. (Plate 2, Fig. 2, l^o. 15.) Situated 
within this space are numerous openings of mucous 
ducts, pointing anteriorly, especially the large and im- 
portant one known as the Lacuna Magna (Plate 2, 
Fig. 2, A^o. 16) ; throughout the urethra, principally 
upon its roof, are found many blind pouches opening 
anteriorly, called the Sinuses of Morgagni (Plate 2, 
Fig. 2, 1^0. 14) , their length being something like 
half an inch, and of a size sufficient to engage the 
point of a filiform bougie. 

The first two points of physiologic narrowing of the 



16 GENITOURINARY SURGERY AND VENEREAL DISEASES. 

urethra are contained within this division, the meatus 
urinarius, and a point posterior to the fossa navicu- 
lars ; found in this division also are the first spaces of 
physiologic enlargement of the canal, the fossa navi- 
culars and its posterior termination, the hulb of the 
corpus spongiosum ; opening into this latter dilatation 
are the ducts of Cowper's glands (Plate 2, Fig. 2, 
'No. 10) , these glands being two bodies the size and 
shape of a pea, situated immediately behind the bulb 
(Plate 2, Fig. 1, IsTo. 7) , their office being the secre- 
tion of a diluent for the spermatic fluid. 

Here is found the Triangular Ligament, a dense 
fibrous fascia attached to the pubis and the rami ischii, 
completely bounding this space, except the aperture for 
the urethra, blood vessels and nerves. Beginning at the 
posterior portion of the spongy or bulbous urethra and 
proceeding backward and slightly upward for three- 
quarters of an inch, we traverse that portion of the 
urethra called the Membranous. (Plate 2, Fig. 1, B.) 
Here is the third point of physiologic narrowing ; here, 
too, is found the voluntary muscular fibres called the 
Compressor Urethrae Muscles ; it is the action of these 
muscles that enables the individual to conclude the act 
of micturition at will ; on account of spasm of this 
muscle instruments are arrested in their passage to the 
bladder, which condition is called False Stricture. It 
is the presence of this muscle that prevents injections 
from being thrown into the bladder. 

Paralysis here is attended with urinary leakage. 
The posterior limit of this second division of the ure- 
thra is in relation to the apex of the prostate gland, 
which point is also the beginning of the third part 
of the urethra, called Prostatic Urethra (Plate 2, Fig. 1, 
A) , and inchides the last one and one-fourth inches of 



ANATOMY AND PHYSIOLOGY. 



the canal, all of which portion is surrounded by the 
prostate gland ; the greater portion of the prostate, 
however, being below the urethra. This portion 
of the urethra is spindle-shape, spacious and dilat- 
able ; within its confines are to be found many import- 
ant structures. A longitudinal, narrow and distinct 
ridge of musculo-erectile tissue upon its floor is called 
the Caputgallinaginis or Veru Montanum (Plate 2, 
Fig. 2, ;No. 5) ; upon either side of this ridge is a de- 
pression, upon the floor of which are situated the 
several openings of the ducts leading from the prostate 
gland, called the Prostatic Ducts. (Plate 2, Fig. 2, 
1^0. 8.) The Ejaculatory Ducts have their mouths in 
a fossa here called the Sinus Pocularis (Plate 2, Fig. 2. 
'No. 6) , which latter is almost one-fourth of an inch in 
length, being upon the floor and beneath the middle 
portion of the prostate. 

The urethra is composed of three coats : A mucous 
or lining coat continuous in front with the semi-mucous 
membrane of the glans-penis and the prepuce, blend- 
ing behind with the lining tissues of the urinary and 
genital organs; it offers lodgment for numerous mucous 
glands within its sub-mucous substance, presenting 
openings therefor upon the surface ; it is covered with 
columnar epithelium, except the anterior extremity, 
where squamous is found. Beneath the mucous por- 
tion of the urethra is the muscular layer, composed in- 
ternally of circular, and externally of longitudinal 
fibres, which order of arrangement is maintained 
throughout the entire spongy urethra, except at the 
bulb, where the longitudinal fibres leave the circular to 
encircle the spongy portion beneath the fibrous fascia, 
joining the circular again at the meatus. Both sets of 
muscular fibres are continuous with the corresponding 
parts of the bladder. 



18 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

Ill addition to the mucous and muscular layers of the 
urethra, there is a thin layer of erectile tissue, arranged 
about the membranous and prostatic portions, which 
latter blends with the corpus spongiosum. 

The function of the urethra is double ; it affords an 
exit for both the urine and spermatic fluid. 

The next organ of generation is the Prostate Gland 
(Plate 2, Fig. 1, 'No. 6) ; it is a musculo-glandular 
organ, measuring one and one-half by one and one- 
fourth inches by three - fourths of an inch in its 
three diameters, being broader than long and longer 
than deep ; it weighs normally about six drachms ; it is 
wdthin the pelvis, embracing the neck of the bladder, 
and the last one and one-fourth inches of the urethra ; 
it is placed behind the deep perineal fascia below and 
posterior to the symphysis pubis, in close relationship 
with the rectum . Its shape resembles a horse-chestnut ; 
it is composed of only two lateral lobes rather firmly 
united. In structure it is distinctly muscular (of un- 
striped kind) , though it possesses numerous glands, 
opening by rather long ducts, which communicate with 
each other, forming fifteen to twenty excretory ducts, 
ending upon the floor of the prostatic urethra. The 
two lateral lobes are securely enveloped within a capsule 
of fibrous tissue, all held in place by the posterior lay- 
ers of the deep perineal fascia, the pubo-prostatic liga- 
ments and a reflection anteriorly of the levator ani 
muscle. The office of this body is, by its muscular 
nature, to contract upon the spermatic fluid within this 
portion of the urethra, causing its spasmodic expulsion 
during ejaculation, while its glandular feature affords 
a thin bluish mucus that mingles with the spermatic 
fluid, diluting it and adding life, giving properties to 
the spermatozoa. The gland is penetrated or tunneled 



ANATOMY AND PHYSIOLOGY. 19 

by the ducts from the seminal vesicles in its upper 
portion. 

The arteries of this body are branches of the middle 
hemorrhoidal and the inferior vesical ; the veins empty 
into neighboring vessels about the parts, the lymphatics 
communicate with the pelvic glands, while the nerves 
are derived from the hypogastric plexus. 

^N^ormally this body does not attain its development 
prior to puberty, and it is usual to note hypertrophy in 
advanced age ; earthy concretions are frequently found 
within its substance. 

The Seminal Vesicles 

(Plate 2, Fig. 1, ^o. 5) are two irregularly lobulated 
pear-shaped containers, measuring from two to five 
inches long, five to six lines broad, and about half as 
deep ; they are placed at the base of the bladder alcove 
the prostate and near the uretral entrance ; they serve 
as reservoirs for the product of the testes, adding 
thereto their own secretion as a diluent and preserva- 
tive ; their relation with each other is V-shaped ; their 
anterior extremities unite with the vasa def erentia, form- 
ing for each an ejaculatory duct, which penetrates the 
upper portion of the prostate, terminating in a verti- 
cal slit upon the floor of the prostatic urethra. These 
bodies may be readily detected with the index finger in 
the rectum above the prostate, and their contents ex- 
pressed by proper manipulation. One substantial 
ejaculation should be the capacity of these vesicles. 

The Vas Deferens 

(Plate 2, Fig. 1, 'No. 4) is that canal or duct having 
its superior or remote beginning at its junction with the 
duct of the seminal vesicle, forming, as it does, the ejacu- 



20 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

latory duct; it is al)out two feet in length, with a 
thickness of one and one-fourth lines, its office being 
the transmission of the testicular secretion to its re- 
spective vesicle ; their walls are firm, elastic and tough, 
conveying to the sense of touch a cord-like hardness. 
]S^ear its union with the duct of its seminal vesicle and 
the prostatic base the vas is somewhat narrowed ; it 
courses upward ; to the inner side of its seminal vesicle, 
near the entrance of the ureter, it curves about the 
epigastric artery and passes external to the external 
iliac ; it courses onward through the internal abdominal 
ring, down the inguinal canal into the scrotum, occupy- 
ing a posterior position in the spermatic cord, becoming 
continuous with the lower and smaller portion of the 
epididymis, where it is called the Globus Minor. 

The Epididymis 

(Fig. 4, ]^os. 16 and 27) is that body occupying a 
position upon the posterior and upper aspect of the 
testicle ; it is but a continuation of the vas deferens, 
])eing a bundle of smaller and much convoluted tubes ; 
as shown (Fig. 4, INTo. 17) it measures in length, when 
teased out, about twenty feet ; it is formed by the con- 
vergence of a system of tubes or ducts known as the 
Coni Vasculosi (Fig. 4) ; it presents two heads, the 
larger at its upper extremity called the Globus Major 
(Fig. 4, Nos. 13 and 24) , the smaller at its lower 
termination called the Globus Minor, and a body which 
is that portion between these two heads (Fig. 4,\N'os. 
16 and 27) . The Globus Major, as before stated, is 
formed from a series of efferent ducts (the coni 
vasculosi) , while the Globus Minor, rather enlarged, is 
attached to the testicle by a fibrous band and some 
loose areolar tissue. The body or central portion con- 



ANATOMY AND PHYSIOLOGY. 



21 



sists of a series of convolutions of the tube loosely 
bound by areolar tissues. Found here also is a blind 
tube from one to three inches long, related to the cord 



Fig. 4. 




Drawn for and under tlie direction of the Author. 



No. 


1. 


iSkin. 


No. 15. 


Spermatic Artery. 


No. 


2. 


Dartos. 


No. 16. 


Body of the Epididymis. 


No. 


3. 


External Spermatic Fascia. 


No. 17. 


Globus Minor. 


No. 


4. 


Cremasteric Fascia. 


No. 18. 


Vas Aberens. 


No. 


5. 


Inf andibuliform Fascia. 


No. 19. 


Median Raphe. 


No. 


6. 


Parietal Layer of Tunica Vaginalis 


No. 20. 


Spermatic Artery. 


No. 


7. 


Visceral Layer of Tunica Vaginalis. 


No. 21. 


Plexus of Veins. 


No. 


8. 


Tunica Albuginea. 


No. 22. 


Artery of the Vas Deferens 


No. 


9. 


Septum. 


No. 23. 


Vas Deferens. 


No. 


10. 


Cavity of Tunica Varginalis. 


No. 24. 


Globus Major. 


No. 


11. 


Lobule. 


No. 25. 


Hydatid of Morgagni. 


No. 


12. 


Mediastinum. 


No. 26. 


Testicle. 


No. 


13. 


Globus Major. 


No. 27. 


Epididymis. 


No. 


14. 


Vas Deferens. 







usually connected with the lower head of the epididy- 
mis, called the Yas Aberrans (Fig. 4, 'No, 18) . The 
remains of the duct of Miiller are small bodies attached 



22 GENITO-URINARY SURGE;RY AND VENEREAIv DISEASES. 

to the epididymis, and occasionally to the testis by 
minute pedicles, which have been termed the Hydatids 
of Morgagni (Fig. 4, 'No. 25). 

The Testes 

(Fig. 4) are two egg-shaped glands, measuring one 
and one-half to two inches by one and one-quarter by 
one inch in their diameters, and weigh slightly less 
than an ounce, the left being somcAvhat larger than 
the right. To these organs belong the office of se- 
creting the spermatic fluid, hence they are the real 
procreating glands of the male ; they are each sus- 
pended in the scrotum by their spermatic cord, made 
up of the spermatic artery and vein, the vas deferens, 
nerves and lymphatics, all bound together by loose 
areolar tissue. 

The testicles are developed and remain during the 
greater part of intra-uterine life within the abdominal 
cavity ; about the time of birth they descend into the 
scrotum. They are each covered by the skin and 
dartos (a contractile tissue) , the latter forming two 
distinct compartments for either testis ; they are more 
intimately covered by the inter Columnar Fascia, 
Cremaster Muscle, Infundibuliform Fascia, Tunica 
Vaginalis, and Tunica Albuginea (Fig. 4). The 
two coverings that are of especial interest are the 
Tunica Vaginalis and the Tunica Albuginea. The 
first is a process of peritoneum brought into this situ- 
ation by the descent of the testis, and afterward being 
shut off from the general peritoneal cavity it forms an 
incomplete covering for the testicle ; it is also reflected 
over the epididymis. Occasionally the communication 
between the general peritoneal cavity and the cavity 
of the tunica vaginalis continues, in which event it is 



ANATOMY AND PHYSIOLOGY. 



usual to find this cavity taken by gut, omentum or 
serous fluid, forming, respectively, congenital hernia, 
epiplocele or hydrocele ; immediately under this and 
directly enveloping the testicle, sending processes into 
the substance of the organ and dividing it into wedge- 
shaped compartments, is the dense white inelastic 
covering (the second of the above - mentioned) , 
known as the Tunica Albuginea (Fig. 4, l!^o. 8) . 
These vertical processes of this material are known as 
the Mediastinum Testis (Fig. 4, ^o. 12), which are 
pierced by blood vessels and contain the seminiferous 
tubes ; radiating processes of connective tissue pass 
from the mediastinum to the inner surface of the tunica 
albuginea proper, thus lobulating the substance of the 
testicles (Fig. 4) ; the number of such lobules to each 
organ is 150 to 200, placed with their apices toward the 
mediastinum and their bases toward the surface . Cours- 
ing along the mediastinum, lining the tunica albu- 
ginea, and following the processes that dip into the 
substance of the gland is a plexus of blood vessels 
and connective tissue called the Pia Mater Testis or 
Tunica Yasculosa. It is withm the cavity of the 
connective tissue where the spermatozoa are gene- 
rated ; the seminiferous tubes found in these spaces 
number to each gland about 800. The lobules making 
up the organ are not of uniform size and shape, the 
larger containing in some instances five to seven semi- 
niferous tubes, while the smallest occasionally a sin- 
gle tube. These tubes are convoluted, and when 
teased out are found to measure twenty -five or thirty 
inches in length with a diameter of 1/244 inch. The 
tube begins by several short, blind extremeties, with oc- 
casional communicating loops ; they pass backward 
toward the posterior aspect of the testicle, uniting to 



24 GEXITO-URINARY SURGERY AND VENEREAI, DISEASES. 

make about twenty straight tubes, known as the Vasa 
Eecta, which latter pass through the mediastinum, 
where the tubes form a net-Avork called the Rete 
Testis ; these tubes anastomose and leave the testicle 
by twelve to twenty openings, called the Vasa Effer- 
entia, which in turn are arranged into masses which 
constitute the globus major of the epididymis. 

The testicle is attached to the bottom of the scrotum 
by a cord called the Gubernaculum Testis. 

The Bladder. 

Posterior to the urethra is a musculo-membranous 
viscus, the Urinary Bladder (Plate 2, Figs. 1 and 2, 
'No. 2). In childhood this organ is within the abdo- 
men, but later its position is in relation, anteriorly, with 
the surface of the pubis, internal obturator muscles 
and triangular ligament; its posterior surface, covered 
with peritoneum, is in relation with the rectum. When 
comfortably filled it will measure about five inches in 
its longest (vertical diameter) , three inches in its 
transverse diameter, and wi\\ hold about fifteen 
ounces. It offers a summit, body and neck; from 
either side of the summit arise two musculo-fibrous 
cords, which are the remains of the obliterated hypo- 
gastric arteries of foetal life ; attached to the summit 
also is a ligament of a similar nature, called the 
Urachus, all of which are inserted at the umbilicus. 

The body of the bladder is related to the vasa defer- 
entia as the latter curves backward upon either side. 

The base is in relation with the second portion of the 
rectum, united therewith by a process of peritoneum, 
while the neck, directed downward and forward, is 
continuous with the urethra, and is surrounded by the 
prostate. 



ANATOMY AND PHYSIOLOGY. 25 

The supports of the bladder, in addition to those 
mentioned, are the Pubo-Prostatic Ligament to the 
anterior surface ; from the sides a fascia from the re- 
spective sides of the prostate ; to the posterior aspect 
are attached two peritoneal folds arising from the re- 
spective sides of the rectum, and latterly two like folds. 
Pour coats compose the organ : 

1st. A peritoneal covering upon its posterior, this 
being reflected from the sides to the pelvis and abdom- 
inal w^alls. 

2d. A muscular coat constructed of fibres arranged 
spirally, forming several layers, the superficial being 
practically longitudinal, while the deep layers are dis- 
tinctly circular ; it is this circular arrangement at the 
neck that makes the sphincter of the bladder, after 
which they are prolonged into the prostatic urethra. 

3d. Beneath the muscular is the cellular layer of 
rather loose areolar tissue. 

4th. The internal or mucous coat, covered upon its 
surface with an epithelium composed superficially of 
polyhedral cells, deeper of club-shaped, and spindle 
cells. 

Mucous follicles are scattered over the inner surface, 
and many racemose glands are located near the neck. 

Viewed from the inner surface of the bladder is seen 
near the neck a smooth triangular ridge (somewhat 
paler than the adjacent tissue, and more firmly attached 
to the deeper layers) , extending outward and back- 
ward upon either side to the respective uretral open- 
ings. This body is called the Trigonum Vesicae 
(Plate 2, Fig. 2, No. 4) , which serves as a conductor 
of the urine. 



26 GENITOURINARY SURGERY AND VENEREAI. DISEASES. 

Projecting into the opening of the urethra is a small 
mass of mucous membrane, called the Uvula Vesicae. 

The blood supply of the bladder is from the supe- 
rior, inferior and middle vesical, with branches from 
the obturator and sciatic arteries. 

About the neck, sides and base of the bladder, the- 
veins form a plexus, which empty into the internal iliac. 

The lymphatics form, for the most part, companions 
for the vessels. 

The Ureters 

(Plate 2, Figs. 1 and 2, No. 1) are two cylindrical 
caiialways, the size of a goose-quill, measuring fifteen 
to eighteen inches in length', connecting the kidneys 
with the bladder, and acting as conductors of urine. 
They are constructed of three coats or layers of tissue : 
an external fibrous, continuous with the capsule of the 
kidney, and that coat of the bladder, a muscular coat 
made of longitudinal and circular fibres, and an inter- 
nal mucous coat presenting several layers of epitheleal 
cells. 

The ureters arising from the pelvis of the kidneys 
pass downward near the abdominal wall, anterior 
to the iliac arteries, beneath the peritoneum, in rela- 
tion with the ilium on the right and the sigmoid on 
the left, entering the bladder obliquely through the 
posterior false ligament close beside the vas deferens, 
about one and one-half inches behind and above the 
prostate. When the bladder is distended the distance 
between the two uretral orifices is about two inches. 
On account of the muscular layer, urine reaches the 
bladder, not solely obeying the law of gravity, but is 
acted on by the muscles of the ureters. The oblique 
entrance of these organs make a valve that presides 
over their bladder termination. (Plate 2, Fig. 2, ISTo. 3.) 



ANATOMY AND PHYSIOLOGY. 27 

The Kidney 

(Fig. 5) is the real urinary organ, for on its account 
many effete principles of the blood are eliminated from 
the economy in the form of urine. They are two bean- 
shaped, glandular bodies, measuring in their three 
diameters four by two by one inch, and weigh from five 
to six ounces. 

They are placed in the lumbar region, upon either 
side of the vertebral column. They extend from the 
eleventh rib to within an inch of the crest of the ilium, 
the right being slightly lower than the left, perhaps on 
account of its relation to the liver. They are posterior 
to the peritoneum, covered by a mass of fat for protec- 
tion, which, together with their blood vessels, hold the 
organs in place. 

The right kidney is in relation upon its anterior sur- 
face to the right lobe of the liver, the ascending colon, 
and the descending duodenum, while the left is in re- 
lation upon its anterior surface to the greater end of 
the stomach, descending colon, tail of the pancreas and 
lower part of the spleen. Upon the posterior aspect 
each rests against the crus of the diaphragm, being 
separated from the psoas magnus and quadratus lum- 
borum muscles by the anterior lamellae of the trans- 
versalis aponeurosis ; their upper portions are capped, 
respectively, by their Supra Renal Capsules (bodies 
whose function is undetermined precisely, though recent 
research has opened a discussion that bids fair to lead 
to definite knowledge). 

Upon the central border of the kidney is a fissure 
about an inch in length, called the Hilum, which com- 
municates with a cavity called the Pelvis (Fig. 5, 
IS'o. 10) ; it is here that the Renal Vein in front leaves 
the organ ; and the Kenal Artery (Fig. 5) reaches the 



28 GENITO-URINARY SURGERY AND VENEREAI. DISEASEvS. 

Fig. 5. 




Semi-diagramatic representation of the Kidney. 
Drawn for and under the direction of the author by L. Crucius, M.D. 



No. 1. 


Capsule of the Kidney. 


No. 


8. 


Arteria Propria Renalis. 


No. 2. 


Grlomerulus. 


No. 


9. 


Infundibulum. 


No. 3. 


Interlobular Artery. 


No. 


1.0. 


Pelvis of the Kidney. 


No. 4. 


Cortical Markings. 


No. 


11. 


Papilla. 


No. 5. 


Pyramids of Ferrein. 


No. 


12. 


Cortical Arch. 


No. 6. 


Labyrinth. 


No. 


13. 


Afferent Branch of Arteria Propria 


No. 7. 


Arterias Rectae. 









ANATOMY AND PHYSIOLOGY. 29 

organ posterior to the vein, with the ureter placed be- 
hind the artery ; here also the lymphatics enter, under- 
neath their fatty covering. 

The kidneys are enveloped in a close-fitting capsule 
(smooth and thin) composed of fibro-elastic tissue 
(Fig. 5, 'No, 1) ; at the hilum this tissue is reflected 
inward to line the pelvis, where it also forms a covering 
for the blood vessels and calices. 

Upon section of the kidneys (Fig. 5) , immediately 
beneath the capsule, is the rather soft, reddish, granu- 
lar striated substance, about one-sixth of an inch in 
thickness, called the Parenchymatous Substance or 
Cortical Layer (Fig. 5, No. 4) , from the under surface 
of which little projections between the pyramids appear, 
known as the Columns of Bertin. 

From the arrangement of the superficial vessels the 
surface of the kidney appears to present a lobulated 
condition ; the organ, however, is not lobulated. In 
the cortical substance are to be found numerous flask- 
shaped bodies, which are the dilated extremities of the 
tubes, giving the granular appearance to this layer. 
These bodies are known as the Malphigian Bodies or 
Tufts. (Fig. 6.) The cortical substance offers a 
fibrous matrix of an intricate and delicate kind, 
supporting the blood vessels and the secreting 
organs ; the tubes found here are by no means of 
uniform size and shape — three distinct varieties are 
met. The tubes connected directly with the Malphigian 
bodies are much convoluted ; the tubes next to the con- 
voluted are smaller ; they dip deep into the pyramids, re- 
turning again to the cortical portion, forming loops; 
next, the connecting tubes, forming a plexus between the 
other tubes with the straight tubes of the pyramids. 

The Malphigian bodies, sometiiues called the Glomer- 



30 ge;nito-urinary surgery and venereal diseases. 

uli (Fig. 6) , are small tufts of blood vessels en- 
closed within a thin membranous covering, called 
Bowman's Capsule, which is lined with nucleated 
epithelial cells ; these bodies receive an efferent vessel 
or artery opposite the urinif erous tubule (of which it is 
the dilated extremity) . After entering the body it is at 
once broken up into a net-work ; here the veins are 
formed which pass out at the same point where the 
artery enters, leaving the uriniferous tubule to begin 
at an opposite point. Within this membranous sack, 
on account of the breaking up of the vessels entering 

Fig. 6. 




7 >8 

Malphigian Corpuscle, or Glomerulus — Semi-diagramatie. 
Drawn for and iinder the direction of the author. 



No. 


1. Artery to Malphigian Body. 


No. 5. EpitheHum of the Tuft. 


No. 


2. Vein Returning Blood from Mal- 


No. 6. Convoluted Blood Vessels. 




phigian Body. 


No. 7. Epithelium of the Neck. 


No. 


3. Bowman's Capsule. 


No. 8. Epithelium of the Tube. 


No. 


4. Epithelium of the Capsule. 





the glomerulus, is the liquid element of the urine 
secreted, together with the urinary salts, while the 
urea, uric acid and other materials are secreted by the 
epithelium of the uriniferous tubules. Thus it will 
be seen that it is in the cortical layer of the kidney 
where the real office of the organ is performed. 

Beneath the cortical zone is the medullary portion 
(Fig. 7) , subdivided into the papillary and boundary 
layer of Ludwig, the former being nearly white ^ 



ANATOMY AND PHYSIOLOGY. 31 

distinctly and uniformly striated, while the latter 
is of a purplish color. The striated portion passing 
to the apices of the pyramids. The medullary portion 
of the kidney is made up for the most part of connect- 
ive tissue and bundles of straight tubes, which become 
smaller and smaller as they approach the periphery. 

In each kidney are found from eight to twelve pyra- 
midal bodies, with their bases directed toward the 
cortical portion and their apices toward the pelvis, 
forming the source of the ureter. 

From Fig. 7 it will be seen that the tubuli urinif- 
eri, beginning with the Malphigian body in the cor- 
tical substance, first presents a convoluted appear- 
ance, which first portion is called the Proximal Convo- 
luted Tube. It next becomes spiral as it approaches 
the medullary substance ; as it enters the medullary sub- 
stance it becomes smaller and rather straight ; passing 
down into the pyramids it turns back, becoming larger 
and spiral again as it enters the cortical layer ; this loop 
is known as the Looped Tube of Henle. which termi- 
nates in an irregular angular fashion ; there is a second 
convoluted portion, called the Distal Convoluted Tube, 
which becomes narrow, next a Curved Tube, then the 
Straight or Collecting Tube, ending upon the top of a 
papilla. 

Fig. 7 will afford a very ready understanding of this 
arrangement. 

The epithelium lining the tubes differ in the several 
portions. 

The blood to the kidney is from the aorta through 
the renal artery, which latter divides external to the 
hilum into four or five primary branches, which 
latter continue subdividing, affording two vessels 
upon the side of each malphigian pyramid, with 



32 GENITO-URINARY SURGERY AND VENEREAI, DISEAvSES. 



Fig 




Semi-diagramatie Representation of Minute Anatomy of the Kidney. 
Drawn for and under the direction of the author. 

Arterife Rectse. 

Pyramid of Ferrein, or a Medullary 
Ray. 

Sub-Capsular Layer. 

Capsule of Bowman. 

Neck of Uriniferous Tubule. 

Proximal Convoluted Tube. 

Spiral Tube of Schaehowa. 
22, 23. Loop of Henle. 
25, Distal Convoluted Tube. 

Curved Tube. 
28. Straight or Collecting Tube. 



No. 


1. 


Capsule of the Kidney. 


No. 14. 


No. 


2. 


Glomerulus. 


No. 15. 


No. 


3. 


Efferent Vessel. 




No. 


4. 


Afferent Vessel. 


No. 16. 


No. 


5. 


Vena Stellata. 


No. 17. 


No. 


6. 


Capillaries. 


No. 18. 


No. 


7. 


Interlobular Vein. 


No. 19. 


No. 


8. 


Interlobular Artery. 


No. 20. 


No. 


9. 


Veinous Arcade. 


Nos. 21 


No. 


10. 


Arterial Arcade. 


Nos. 24 


No. 


11, 


Vein. 


No. 26. 


No. 


12 


Arteria Propriarenalis. 


Nos. 27 


No. 


13. 


Venae Reetse. 





ANATOMY AND PHYSIOLOGY. 33 

branches to the malphigian bodies in columns, passing 
to the bases of the pyramids and cortex, where smaller 
branches, called the Inter Lobular and Arteriae Rectae, 
are developed. 

The venous blood passes out through the hilum, 
through the renal vein, into the inferior vena cava. 

The nerves found in the kidney number about fif- 
teen; they are small, possessed of ganglia, and are 
derived principally from the solar plexus, semi -lunar 
ganglia and lesser splanchnic. 



CHAPTER II. 

DEFORMITIES OF THE PEXIS— TRAUMATIC AFFECTIONS OF THE 
PENIS— CUTANEOUS AFFECTIONS OF THE PENIS— TUMORS OF 
THE PENIS— LYMPHATIC AFFECTIONS OF THE PENIS— 
PHIMOSIS— PARAPHIMOSIS — HERPES PROGENITALIS— 
VENEREAL WARTS— BALANITIS— POSTHITIS— OSSI- 
FICATION OF THE PENIS— CALCIFICATION OF 
THE PENIS— HYPOSPADIAS— EPISPADIAS 
CIRCUMCISION— AMPUTATION 
OF THE PENIS. 

Anomalies of this organ of a more or less pro- 
nounced nature exist more abundantly than many be- 
lieve. The esteem with which the sexual organs are 
held by man is interesting ; irregularities of the parts, 
especially of the penis, develop in the possessor strange 
and wonderful fancies ; and for reasons of this kind it 
is often late, and oftener never, that such individuals 
present themselves to the surgeon for relief. In the 
processes of evolution the penis may be undeveloped, 
or it may be excessive in size. When the organ at- 
tains a length of nine inches, when flaccid, or when no 
longer than two inches when erect, it may be said to 
be deformed. Rarely there is developed two such or- 
gans ; rarely also is there none. Fig. 8 represents, 
perhaps, the most interesting specimen that medical 
literature offers. 

In the London '^Lancet," January, 1866, we are 
informed that this monster was a well-developed man 
presenting a third but imperfect leg, with double foot 
and penis ; that both these latter organs became erect, 



DEFORMITIES OF THE PENIS. 



35 



a>nd discharged semen at the same time, also that 
urine would flow from the urethra of either simultane- 
ously and at will. 

When no penis is observed, the urine is usually 



FiCx. 8. 




Double Penis. 

passed through the rectum ; occasionally the penis pre- 
sents a twisted appearance ; other defects are observed, 
some of which will be mentioned later. 

The treatment for the above deformities must of 
course be surgical, and then only when circumstances 
admit. 



36 GENITO-URINARY SURGERY AND VENEREAI. DISEASES. 

Traumatic Affections. 

From the anatomical formation and situation of the 
penis it is only occasionally the subject of legitimate 
injury. Contusions are attended, as a rule, with undue 
extravasation of blood, due to its vascularity and loose- 
ness of connective tissue. Such situations are best 
treated with conservatism ; the application of hot or 
cold compresses, rest, full dose of potass, brom. (40 
grains), to prevent erection, and an active cathartic 
Avill in most instances accomplish good ends. Incision 
into such a part should be performed under strict 
surgical cleanliness, for infection here might be at- 
tended with extreme consequences. Active inflamma- 
tion and suppuration might be followed by gan- 
grene, that would develop a deformity which would 
lead to painful and imperfect erection. For the most 
part, however, injuries of this part come as a result of 
mental derangement and toying with the parts. Many 
interesting cases are on record where perversion of 
the sexual dictate has led to mutilation and even de- 
struction of the penis. In the writer's experience sev- 
eral pitiable instances have occurred from such insanity. 
Those injuries involving the urethra will be treated 
under the latter heading. 

The penis maybe fractured under proper circum- 
stances ; this could occur when the member is rigidly 
erect, if forcibly and suddenly flexed. Such a condition 
should be at once examined, extension made, and an 
elastic support applied throughout its entire extent, bear- 
ing in mind the importance of providing for, and preven- 
tion of, erection. An injury of this nature is liable to 
iiivolve the urethra, when retention of urine, followed 
by infiltration , and those serious consequences are to be 
expected. Should this serious complication occur, no 



TRAUMATIC AFFECTIONS OF THE PENIS. 37 

time should be lost in readjusting the urethra and hav- 
ing a catheter reach the bladder. Failing in this it 
becomes necessary to open the canal in the perineum, 
which is the most available point for an external open- 
ing, and in this way alone obviate the dangers incident 
to extravasated urine ; sounds should be passed regu- 
larly, and the treatment for prevention of traumatic 
stricture adopted. It is well in all such situations to 
look to the general health, especially the urine, giving 
some such prescription as — 

No. 1. 

^. — Aeidum benzoieum 5ii- 

Ext. hyoseyam. fid... 5i- 

Ext. stigmata maydis, fld ^ii. 

Tr. Cinehon. eo ^n. 

M. ft. sol. 
S. — A teaspoonful in a wineglassful of water every 
three or four hours. 

Hemorrhage, which, as a rule, is excessive in all in- 
juries of this part, may be controlled by introducing a 
full size sound and applying a close-fitting bandage. 
Erections should be controlled. Rx. l^os. 2 and 3 will 
be of service. 

No. 2. No. 3. 

^. — Potassii. brom '^vi. I^. — Hydrat. chloral 5iiss. 

Camph. mono. brom. gr. xvi. Tr. hyoseyam TIJ'. xxxii. 

M. ft. chart, No. xii. Aquee e amphorae ....giv. 

S.— One powder in water every M. ft. sol. 

three or four hours when necessary S. — A teaspoonful in water every 

to subdue erections. four to six hours to secure rest and 

sleep. 

The old practice of breaking the chord in chordee 
during an attack of gonorrhoea is to be condemned. 

Dislocation 

of the penis may result when the prepuce becomes en- 
gaged in a way as to force the glans -penis backward to 



^^fifmsBr 



38 GENITO-URINARY SURGERY AND VENEREAI. DISEASES. 

an extent that the semi-mucous membrane at the corona 
or prseputial orifice gives way, permitting the penis 
proper to be pushed into the scrotum or upon the pubis. 
Prompt reposition of the organ is the treatment; 
reverse the order of the force that was responsible for 
the accident as nearly as possible. A long tenaculum 
may be hooked into the glans-penis, traction applied, 
assisted with manipulation from behind, and the mem- 
ber may be dragged into place. Occasionally the 
penis seems lost, and nothing short of free opening up 
of the area will enable its location and correction. Re- 
tention of urine here is to be treated as elsewhere ; 
the trocar and canula may be used by cleansing the 
area and puncturing the bladder in the median line, an 
inch above the symphysis pubis. 

The Cutaneous Affections 

of the penis are those common to other cutaneous sur- 
faces, and demand appropriate treatment ; it is possibly 
more important here to recognize these skin lesions 
than elsewhere, as upon this part the presence of such 
disease will often give rise to anxiety, fear and appre- 
hension that is painful. Elephantiasis is common ; 
erysipelas of a phlegmanous type may arise and offer 
serious results. 

Tumors 

may also be found here, which may be malignant or 
benign ; the most frequent of the cancerous type is 
epithelioma ; other forms are rare. To distinguish 
epithelioma from other affections, reference to table, 
page 43, should be had. The treatment for epithe- 
lioma is surgical and should be radical. It is my cus- 
tom, prior to general disturbances, when the disease 
seems local, first, to freely dissect out the growth, then 



CUTANEOUS AFFECTIONS AND TUMORS OF THE PENIS. 39 

with a thermo-cautery thoroughly destroy the under- 
lying structures, dressing the wound by packing with 
iodoform gauze. I watch attentively the outcome of 
this operation, and upon the first evidence of return I 
advise amputation of the penis in its entirety, together 
with the removal of the testes, and the superficial chain 
of lymphatic glands upon either side. Radical as this 
may seem, nothing short can be depended upon for per- 
manent relief, and even then relaj^ses frequently occur. 
Several times I have been induced to apply an eschar- 
otic, but have found that the lymphatic disturbances 
following is too extensive. 

Fatty, cystic, erectile and fibrous tumors are here 
met ; treatment therefor consists in their removal, when 
their size, situation or presence is responsible for 
discomfort, physical or mental ; and the resulting scar 
will be of lesser inconvenience than the original 
trouble. 

Cutaneous horns, springing from the skin glands, 

appear upon the penis ; they are hard, of a dirty brown 

color, and slow growth. Treatment should be : free 

curettage of the base and the subsequent application 

of a caustic. (Citric acid, chromic acid or nitrate of 

silver.) 

Diseased Conditions of the Lymphatics, 

presenting an oedematous, boggy appearance, and fre- 
quently with few subjective symptoms, are noticed 
as a result of some disturbing agent upon the lym- 
phatic vessels. Such a condition may be due to the 
existence of any form of venereal disease, to the action 
of any irritating agent, and frequently without assign- 
able cause. Treatment consists in the removal of the 
element that is responsible. The application of Rx. 
ISTo. 4: 



40 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

No. 4. 

I^. — Liq. plumb, subaeet. dil o'^iii- 

Tinetura opii ^i. 

AqufP Camphorpe gvi. 

M. ft. lot. 
S. — Use locally on cloths. 

Apply by wetting several layers of gauze and cov- 
ering with rubber tissue ; repeat once or twice daily. 
Should much swelling exist, especially about the pre- 
puce, the i3art may be punctured in several places, the 
exudate milked out, and the dressing applied. 

Phimosis 

is that stenosed or narrowed condition of the prepuce 
which prevents the glans-penis from being uncovered. 
This defect may be congenital, or it may be acquired 
through the action of inflammation or injury. Such a 
state l3egets much trouble, and is within itself the 
source of much annoyance. Treatment is circumcision 
when conditions are favorable. 

Paraphimosis 

(Fig. 9) is that condition of prepuce or glans-penis 
preventing the return of prepuce when once it has been 
retracted behind the glans. When the constriction is 
brought to bear upon the glans-penis the return of 
blood is either' arrested or obstructed in part. There 
is at once necessity for attention, that gangrene, pain 
and swelling may be prevented. After cleansing and 
anointing the part, the prepuce should be grasped, 
the circumference of the glans decreased by pressure, 
and the part reduced (as illustrated by Fig. 10) ; fail- 
ing in this, the prepuce should be slit upon the dorsum 
until all constriction is overcome, after which, if the 
integrity of the parts will admit, circumcision should 



PHIMOSIS AND PARAPHIMOSIS. 



41 



be performed. There are other methods for 2)reYeii- 
tion of this condition, consisting in enlarging the pre- 
putial orifice, that need only be mentioned, for gradual 
and forcible dilatation in adult life are operations quite 
absurd. 

Fig. 9. 




Paraphimosis. 

Drawn from nature for the aiithor by Dr. L. Cruems. 



Fig. 10. 



&m 




Eeduetion of Paraphimosis. 
Dra-WTL from nature for the author by Dr. L. Crucius. 

Herpes Progenitalis 

is a local cutaneous affection appearing upon any part 
of the penis, preferably upon the semi-mucous sur- 
faces. Clusters of vesicles that are quite discrete at 



42 GENITO-URINARY SURGKRY AND VENEREAL DISEASES. 

first, but from their situation become irritated by un- 
clean discharges and coalesce. These lesions make their 
appearance rather suddenly, and frequently become 
eroded, the vesicle or vesicles then present an erythema- 
tous base ; occasionally pain of a neuralgic character 
attends the development of such an attack, also gen- 
eral nervous disturbance at times is noticed ; an un- 
comfortable burning and itching is not unusual. 
Certain dispositions favor the development of this 
disease — rheumatism, gout, diabetes and the neurotic 
state . One attack favors another, and any condition 
that begets an uncleanly state predisposes to it. 

Herpes Progenitalis may or may not be of venereal 
origin, and is to be distinguished from several import- 
ant conditions by reference to table, page 43. 

The treatment of this affection is : cleanliness in all 
that the term implies ; the individual lesions may, with 
advantage, be touched with nitric acid or nitrate of 
silver, especially if ulceration develops, first applying 
five per cent solution of cocaine to allay pain. If the 
glans-penis can be kept uncovered, a lead and opium 
application may be used. I find tannate of glycerine, 
undiluted, of great benefit, applied twice daily. The 
dry powders are of service. Prescriptions 5, 6 and 7 
may serve the purpose. 

No. 5. 

I^. — Bismuthi sub ultras \ ^r- 

Acidum boricum '. j "^ 

Pulv. campliorse gr. xii. 

M. ft. pulv. 
S. — Apply to the parts three or more times daily. 



No. 6. 
^. — Aeetanilid 

Acidum boricum j- aa 5i- 

Zinci oxidum 

M. ft. pulv. 
S. — Apply three or more times daily. 



1 



HERPES PROGENITALIS. 



43 



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44 GENITO-URINARY SURGEIRY AND VENEREAI. DISEASES. 

No. 7. 

R.— Aristol \ ^. 

Greta preperata J ^^ '^^* 

Unguent, aquae rosse 5!. 

M. ft. Unguent. 
S. — Apply to the parts on cloth. 

Campho-phenique powder is good. Stearate of zinc, 
with aristol ; in fact, any non-irritating antiseptic ap- 
plication. Attention should be given to any irregu- 
larity of constitution or habit. Rx. ^o. 8 or some 
appropriate alterative should be prescribed in those 
recurring cases. 

No. 8. 

R. — Aeidum arsenosum gr. i. 

Strycli. sulph gr. ii. 

Ferrum reduetum qi. 

Quininse sulphas 5i- 

Resina podophylli gr. v. 

M. ft. pil., No. Ix. (in caps.) 
S. — One after each mea/1. 

Venereal Warts, 

as will be observed from Fig. 11 (which is rather an 
extreme example), are papillary overgrowths, highly 
vascular, presenting a rough, warty or cauliflower con- 
tour. This condition may appear as a single, insig- 
nificant vegetation, either upon the semi-mucous sur- 
face, or upon the skin, or extensive areas may become 
the seat of such disease ; any unclean, moist area 
favors their development; there is a decided tendency 
to spread, and no doubt there is an element of con- 
tagion ; a characteristic, disagreeable odor is usually 
noticed. Large growths may present a small pedicle, 
or a small growth may have a relatively large pedicle. 
The treatment is very much the same as for herpes 
progenitalis : cleanliness, freeing the parts of moisture, 
applications of solution perchloride of iron, pure tannic 
acid, etc. When local treatment fails to produce de- 



VENEREAL WARTS. 



45 



cided effects, the groAvths should be Hfted and clipped 
off with scissors, the scar touched with nitric acid, and 



Fig. 11. 




Venereal Warts. 



the parts treated to dry, antiseptic, non-irritating dress- 
ings. Circumcision is almost ahvays indicated. 



46 GENITO-URINARY SURGERY AND VENEREAI. DISEASES. 

Balanitis and Posthitis 

are terms expressing an inflammation respectively of 
the semi-mucous membrane of the glans-penis and of 
the prepuce. The one rarely exists for any length of 
time without giving rise to the other. These two con- 
ditions are developed very much from the same causes 
that are responsible for herpes progenitalis and venereal 
warts. Venereal diseases, on account of acrid dis- 
charges, disturbing the nutrition of the surfaces, are 
responsible, the same as other agents capable of pro- 
ducing like disturbances. The most extensive attack 
that has come to my notice was due to the parts being- 
dusted with a poAvder prepared for cold feet. The 
patient believing the head of his penis to be too cold 
and damp applied a powder that had been used with 
satisfaction upon his feet, Avith the effect of producing 
a rawness of these surfaces, followed by ulceration, 
great swelling and 2>ain. 

The entrance into the circulation through these 
abraded surfaces of pas-producing micro-organisms 
occasionally results in extensive ulceration, bubo, etc. 
The usual appearance of the surfaces in this disease is 
what would be expected ; should boiling water be poured 
upon the parts, the mucous membrane is reddened 
and inflamed, slips off in patches, leaving a denuded 
and tender surface. 

In the treatment, cleanliness is of first importance. 
The remedies known as the bland, antiseptic, dusting- 
powders are in order. Prescriptions 9 and 10 suggest 
themselves : 

No. 9. 

^. — Tannate of glycerine S^- 

Fl. ex. of belladonna ^i. 

M. 

S. — Wash the parts and apply with gauze twice a day. 



AMPUTATION OF THE PKNIS. 55 

Amputation. 

Amputation of the penis is necessary at times in 
consequence of a gangrenous state, due to infectious 
processes, or to traumatism. Mature judgment is to 
guide one in passing upon so important a proposition; 
and amputation under these circumstances is to be ad- 
vised only after dihgent conservative measures have 
failed, or from the very nature of the situation the life 
of the patient would be jeopardized by delay. 

Amputation of such a portion of the penis is done as 
will meet the desired aim. 

Those malignant processes (especially epithelioma), 
demand, as a rule, amputation of the entire organ, to- 
gether with the removal of all lymphatic glands in any 
way involved. I believe, too, that no better and no 
more generous turn canbedone the unfortunate patient 
than at the same time perform double castration. By 
the removal of the penis alone those natural sexual de- 
sires continue, with no prospect or possibility of natural 
gratification ; and on this account the life of such an 
individual might become a burden and a disappoint- 
ment in many ways. There are a number of methods 
for doing this work. Should amputation of a portion 
of the organ be decided upon, it Avill be well to remem- 
ber that the remaining part of the member may retract 
after division, carrying with it the open blood vessels 
to a degree that will lend embarrassment to the situa- 
tion. When amputation is done upon the posterior 
pendulous portion, the part should be transfixed with 
long pins, or anchored with a substantial suture. A 
sound introduced into the canal, and the penis pulled 
forward, greatly facilitates the work. A circular in- 
cision through the skin, anterior to the proposed 
division, is made, the skin retracted, the corpora caver- 



56 GENITOURINARY SURGERY AND VENEREAL DISEASES. 

nosa and the corpus spong-iosum are divided down to the 
urethra, all bleeding is controlled, the urethra grasped 
witli two small forceps from either side, the sound re- 
moved ; the urethra is now divided one-fourth to one- 
half inch anterior to the division of the corpus spongi- 
osum proper; a vertical slit is made into the urethra, 
dividing its j)i"ojecting portion into two lateral flaps, 
which are united with fine sutures to the skin flaps of 
the respective sides — the skin from below and above is 
likewise attached to the upper and lower portions of 
this mucous tissue. 

I have found that the elasticity of a generous mucous 
flap of this kind will enable one to cover the end of the 
stump. The ecraseur and the galvano- cautery have 
been used for amputation here, w^ith the view of ob- 
viating hemorrhage. Personally, I have not been 
impressed with such a procedure, hence I have no ex- 
perience wdth either. The entire penis may be removed 
with or Avithout castration ; I have always advocated 
castration in such cases, for reasons briefly mentioned, 
and, as a result, most of my complete amputations 
meant amputation and castration. Another reason for 
castration is, that amputation is almost always done 
for malignant disease ; where the testes remain there 
is little rest of the genital organization — a condition 
much desired when dealing with pathologic conditions 
so prone to recur. 

M}^ method of removing the entire penis is a modi- 
fication of Delpeche's, which was known in 1837. 

If castration has been agreed upon, I first remove 
the testes and excise the inner half of either scrotal 
sac (or the middle half of all scrotal tissue). If cas- 
tration is not done, the median raphe is carefully dis- 
sected, beginning at the anterior scrotal angle, and 



AMPUTATION OF THE PENIS. 57 

carried to th^ posterior scrotal angle, thus dividing the 
pouch into its two compartments, containing in either 
its testicle. 

The operation from this feature on to its completion 
is applicable in either situation. 

The membranous urethra is now opened and fixed 
(temporarily) . All the tissue down to Buck's fascia 
is divided about the root of the penis, the crura of the 
corpora cavernosa are dissected from their attach- 
ments, bleeding vessels caught w^ith long forceps and 
secured ; the urethra at its membranous portion is 
freed, and planted in the median line in the perineum, 
by uniting it wdth the scrotal tissue. (The introduc- 
tion of a sound in this operation is an advantage.) 



CHAPTEE III. 

THE PROPER CURVE OF THE URETHRA— PROPER CURVE OF IN- 
STRUMENTS — IMPERFORATION AND ATRESIA OF THE 
URETHRA— CATHETERISM—HERMAPHRODISM— URI- 
NARY FEVER— HYGIENE OF THE SEXUAL AND 
URINARY ORGANIZATION— FOREIGN 
BODIES IN THE URETHRA. 

Rather distinct knowledge of the proper curve of 
the urethra can be had from the anatomy. 

The natural curve of the urethra is the guide in the 
construction of urethral instruments. Hence, the 
curve of instruments should be identical with the curve 
presented by the normal urethra. It is quite import- 
ant that this lesson be impressed, for much, and un- 
necessary, injury is often done these parts for want of 
this information. 

A rule for the selection of instruments that I have 
found applicable to the greatest number, and one al- 
ways at hand, is the fourth part of the circumference 
of a circle having a diameter of 3^ inches, as illus- 
trated by Fig. 15. The sound A.B.E. is the most ap- 
plicable. From frozen sections and plaster injections 
of the normal urethra, I am convinced that this is the 
curve of the average urethra; this, too, is the experi- 
ence of Thompson, Gouley, Van Buren and others. 
Otis and Bumstead recommend the short curve F.B.E., 
while Benique advocates the longer and different one 
C.B.D. 



the; proper curve of the urethra and instruments. 59 
Fig. 15. 




Showing curve for urethral instruments. 

The sound represented by the letters A.B.E. is that curve or shape 
recommended by the author. 

Imperforation and Atresia of the Urethra. 

Congenitally, the urethra may be nuperforate ; the 
irregularity may be confined to the meatus or its im- 
mediate vicinity, consisting of a mere partition, only 
necessitating puncture with a trocar, or dividing with 
a knife, continuing the opening by the passage of 
sounds. Or, the obstruction may be very extensive, 
the urethra being taken, partially or completely, by a 
fibrous material, which condition is more properly 
called Atresia. 

When either imperforation or atresia exists for any 
length of time after birth, the situation at once be- 



60 GENITO-URINARY vSURG^RY AND VENEREA!. DISEASES. 

comes alarming, except nature has provided another 
outlet for the urine, which would be through the open 
urachus, or into the rectum. 

The treatment for this defect is surgical ; if there 
can be found a portion of the urethra that fluctuates, 
an incision here would liberate the retained urine, and 
afford time for the correction of the irregularity. Other- 
wise, a dissection of the urethra throughout its occlud- 
ed portion (from meatus to the bladder, if necessary) . 
This operation should be along the lower median 
aspect of the corpus spongiosum. Failing in your 
purpose, the trocar may be resorted to for temporary 
relief, when a second attempt at correction of the de- 
fect may be successful. 

Catheterization, Sounding, or Exploration of the Urethra 

are terms expressive of the art of applying instruments 
to the bladder by way of the urethra ; the term is ap- 
plicable to instruments made use of in this way, 
whether they be Catheter, Sound, Bougie, Staff, or 
Searcher, soft or hard, flexible or fixed. Preparatory 
to the introduction of instruments, it is imperative that 
strict surgical cleanliness prevail. 'No instrument 
should be used that has not been cared for. No ouit- 
ment or lubricant employed that is not sterile. Soft 
instruments are lubricated and passed w^ith little regard 
for the urethral curve ; their blunt or olive points will 
naturally adapt them to the part. The English and 
French instruments will obey in a like manner. The 
metal and fixed instruments, however, are to be used 
with greater caution and understanding. When the 
urethral curve and the curve offered by the instru- 
ment are appreciated, the fitting of the one to the other 
is a matter of the greatest ease, and a metal instru- 



CATHKTERISM. 



61 



ment can then be applied with corresponding facility 
and satisfaction. It should be remembered that a 
sonnd or metal instrument in the hands of a surgeon 
is nothing less than a lever. A few ounces of misdi- 
rected force upon the handle will return many pounds 
of damaging pressure at its other extreme. There is 
no physician or surgeon who is not called upon to per- 
form this operation. I have been pained to see much 



F](s. 16. 





First position in the introduction of a sound. 



bungling work here, at the hands of those who should 
show greater skill. 

The sound should be maintained with its point 
always following the course of the urethra; little force 
is required — the Aveight of a solid instrument is often 
sufficient where no obstruction is found; the urethra 
should be drawn over the instrument rather than force 
the instrument through the urethra. 



62 



GEINITOrURINARY SURGERY AND VENEREAL DISEASEvS. 



With the patient upon his back, the legs sUghtly 
flexed and separated, the surgeon upon his left, the 
penis is lightly grasped at its neck by the index finger 
and thumb of the left hand ; the sound (warmed and 
oiled) is entered parallel to Poupart's ligament (Fig. 
16) . Its weight, assisted by adjusting the penis, 
will carry the point to the anterior surface of the 
curved or fixed urethra ; now gently rotate the in- 
strument toward the linea alba (Fig. 17) and it will 



Fig. i: 




Second position in the introduction of a sound. 



be observed that the point enters the curve of the ure- 
thra as the instrument is raised from the abdomen. 
When the perpendicular has been reached (Fig. 18), 
the point of tlie instrument has traversed the curve ; 
by depressing the handle of the instrument its point en- 
ters the bladder (Fig. 19). To remove the instrument, 
reverse the motions necessary for its introduction. 'No 
pulling is necessary ; simply raise the handle to the 
perpendicular ; carry it forward until it is in relation to 
the linea alba ; describe an angle of forty-five degrees 



catheterism. 
Fig. 18. 



63 





Fourtli and last positipn, the sound having entered the bladder, 



64 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

upon the same plan, all the while crowding the penis 
back ; now elevate the remote end of the sound with 
its point downward and the penis drops from it. 

Hermaphrodism. 

The condition indicated by the term ' 4iermaphrodite' ' 
is one that might well have been disposed of under the 
caption ' 'Hypospadias/' for the vast majority of such 
monsters are but extreme examples of that defect. 
However unimportant it may be from a strict medical 
and surgical attitude, yet a brief mention of the inves- 
tigations made by the author into these matters may 
not be lacking in interest and scientific worth. I have 
never seen a being possessed of double gender, to a 
degree of full sexual potence, in either capacity, yet I 
am quite positive that many times it is difficult to decide 
which sex a given individual has a right to claim. The 
two illustrated cases represent the most perfect exam- 
ples of these monstrosities that has come to my notice. 
The first case (Fig. 20) is a photograph taken at my 
clinic, December 21, 1895. I quote from my remarks 
upon that occasion : 

^'P. S. was born in the town of , County of 

^ — , State of , on the 18th day of May, 1868 ; 

father, an American Indian ; mother, English. Has 
three brothers and one sister, all normal, all married, 
and all have children. Occupation, bare-back rider. 
Her early association was that of a female. She was 
reared, dressed and considered as such. Has men- 
struated rather regularly since the age of eighteen. 
At one time missed for three consecutive months • 
Suffers some pain in the back, abdomen and breasts 
during this epoch, the flow being bright red and thin. 
There is no leucorrhoeal discharge. Has never copu- 



\, 



HHRMAPHRODISM. 



65 



lated with a male ; never had a desire. Has been mar- 
ried to a Avoman for three years. Has substantial 
erections once in twenty-fonr hours. Copulates two 
or three times a week and experiences the usual sexual 



Fio. 20. 




Pauline S., Hermaplirodite. 



pleasure. Has no regular ejaculation of seminal fluid, 
but a copious discharge of colorless, limpid fluid.'' 

With this outline of unauthentic history, I now pre- 
sent to you P. S. 

"'Gentlemen, as this character stands before you, 
clad in the habiliments of femininity, I am unable to 



66 GENITO-URINARY SURGERY AND VENEREAL DISEAvSES. 

detect any radical departure from the usual type of 
womankind, occupying the lower plane of society. The 
face in contour is distinctly feminine. Her skin is de- 
void of hair, soft and elastic. When she speaks it is 
with a masculine voice. 

''Removing her clothing we discover the neck and 
chest of a man, no mammary development, with arms of 
a woman and the hand of a man. The abdomen is like- 
wise masculine, the hips and pelvis a compromise, the 
distribution of hair, prominence of symphysis pubis, 
feminine. Thighs masculine, leg and foot feminine. 
Height, five feet four inches ; weight, 146 pounds ; 
complexion dark. I hardly think it necessary to now 
call your attention to the genito-urinary neighborhood, 
for I am convinced that this region has thus far com- 
manded your attention. However, I find this member 
to clearly be a penis. Looking at it from above it 
could not well be mistaken for anything else. In its 
present state of repose it measures three and one-half 
inches in length, and exhibits the usual make-up, so 
far as pigmented skin, corpora cavernosa, glans-penis 
and prepuce are concerned, all under size. Ex- 
amining from below, I discover the corpus spongiosum 
has failed to unite, leaving a cleft throughout the 
entire pendulous portion. I further find, in ad- 
dition to the loose tissue on either side of the unde- 
veloped corpus spongiosum urethrae, and occupying the 
usual site of the female labia majora,two large tags or 
flaps of pigmented tissue, lined upon their inner aspects 
with mucous membrane, clearly showing that nature had 
at least done some work with the labia major a in view. 
Between these bodies can be plainly seen an aperture, 
having the resemblance of a vagina, with an opening 
that you discover readily admits my index finger. 



HERMAPHRODISM. 67 

Passing backward for about two and one-half to three 
inches, the finger is w^ell within a receptacle having the 
appearance of a cul-de-sac or blind pouch, rather roomy 
at the bottom. It is now that I search for the os-uteri, 
or other female organs of generation. In this search 
I fail to detect anything that could be accepted for a 
uterus or ovaries. Another search proves equally 
fruitless. Hence we must doubt the correctness of the 
statement that she menstruates. I, however, detect 
about midway in the roof of this vagina an opening, 
which is the meatus urinarius. Here, also, I discover 
a body that I take to be a prostate ; it is small, irregu- 
lar, but a median fissure is detected. Arising promi- 
nently from the base of the penis, on either side, we 
have a scrotum in two sections, each containing a testi- 
cle, normal so far as the spermatic chord and epididymis 
can make it. The impression these bodies afford me 
is that, as a male, the patient is well represented. 
Passing the finger up the rectum I again detect an 
apology for a prostate. This body is insignificant as 
compared with a normal gland. In this locality I am 
still unable to detect either uterus or seminal vesicles, 
though I am inclined to believe these latter do exist. 

" This, then, concludes the examination. When your 
professor of anatomy. Dr. Keiffer and Dr. Bond, have 
examined, the class Avill form in procession, as before 
suggested, when each of you may personally examine, 
after which a photograph will be had. 

^'In conclusion, I will give it as my opinion that 
nature, in her efforts to determine the sex of this speci- 
men, became involved in some confusion, and the result 
of her efforts certainly exhibit evidence of double gen- 
der, tinctured especially with masculinity. 



68 



GE^:^TO-URINARY SURGERY AND VENEREAL DISEASES. 



^'Congratulate yourselves for being able to examine 
this rare and interesting monster.'' 

Fig. 21. 




Hermaphi'oclite. Compliments of Dr. B. Merril Ricketts. 

The second case (Fig. 21) comes as a compliment 
from my friend, Dr. B. Merril Ricketts, of Cincin- 
nati, Ohio. 



URINARY FEVER. 69 

The age of the patient at time of her death was 
thirty-three years ; had a fair-size penis, four inches 
long while flaccid ; a vagina that was roomy. Was 
married to a man, but could copnlate with a woman. 

Urinary Fever. 

A form of fever following urethral instrumentation, 
and manifesting itself in one of three ways, has been 
denominated Urethral or Urinary Fever. For many 
years, and even to-day, some hold that this fever is the 
result of nervous shock, and offer no rational explana- 
tion for its occurrence. I could never reconcile myself 
with such a position ; in fact, I have always maintained 
that which is now generally accepted and demonstrated 
concerning its etiology. 

Urinary fever, then, is a septic infection which may 
be occasioned by the introduction of instruments bear- 
ing unclean matters, which material is deposited upon 
abraided or susceptible surfaces, from which absorp- 
tion into the general circulation takes place ; or, by 
the absorption of septic material already within the 
urethra, the instrumentation so disturbing the con- 
tinuity of the urethral mucous membrane, or altering 
its nutrition, as to afford an avenue for absorption : or, 
the absorption into these areas of infectious elements 
coming from beyond the urethra. 

This fever, then, could be conveniently divided into 
three classes, and each, given distinct notice, yet I will 
endeavor to so treat the subject generally as will ob- 
viate the necessity of so doing. 

If, then, the urinary organs are in a healthy 
state, the urethral instruments surgically clean, and 
handled properly, there can be no possible danger of 



70 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

exciting such an attack. When such an ideal condi- 
tion of things exists there is seldom need for instru- 
mentation; it is in the face of diseased conditions, 
when dehris occupies the field, that we are called to 
explore this area ; our greatest and best efforts then 
lie in the direction of preventing such an infectious 
process. The urine should be carefully investigated, 
the bowels and skin looked after, the urethra irri- 
gated, etc. 

The character of the pus-producing element that is 
present, and the soil upon which it is sown, are the 
essential factors governing the type of urinary fever. 
The disease may express itself in all grades of severity. 
The usual display of symptoms and conditions, begin- 
ning with the first act of micturition following urethral 
exploration, being a chill (mild or severe), promptly 
followed by fever ranging from 102 to 105 de- 
grees F., and then by a sweat proportionate to the 
fever. This, together with neuralgic pains, nausea or 
vomiting, may constitute the attack, and the patient 
at once becomes convalescent. If the infectious ma- 
terial be more potent, or the patient exhibits a greater 
susceptibility, or diminished resistance, all of the above 
characteristics Avill be heightened. The chill may be 
extreme and greatly prolonged, continuing for hours ; 
the fever may run high, the skin hot and dry ; delirium, 
vomiting and purging may be a part of such an attack ; 
the kidney functions may become arrested, and every 
feature of extreme septic infection followed by col- 
lapse and death. Or, the condition may be interme- 
diate, instead of convalescence being established as in 
the first, or of the rapid fatal issue as in the second ; 
there may be a number of chills, followed by a septic 
condition, that may appear rather insidiously several 



URINARY FEVER. 71 

days, perhaps, after urethral surgery and continue for 
weeks, eventually ending in recovery, only after the 
vitality of the patient has severely suffered. 

It is now known that this fulminating and fatal form 
of urethral fever is largely due to damage already done 
the kidney by former disease. 

In my private work I have not seen urethral fever 
of any note for several years. The prognosis of this 
disease depends upon the factors present, and should 
be guarded at all times. 

The treatment, in addition to those measures look- 
ing toward its prevention (which are by far the most 
satisfactory) , is local and internal. Absolute rest. 
Iron, Quinine and Strychnine in combination. Rxs. 
No. 11 and ^o. 12 will be found useful as tonics, and 
will indicate the character of medication called for : 

No. 11. Xo. 12. 

^.. — Hydrarg. bi. ehlor gr. ii. ^. — Litliii. bromidum 5iv. 

Tr, feiT. ehlor 5"!- Elix. saw -palmetto ^ 

Syr. simp ^iv. ^^^ santal eo ^aa gii. 

^j^ Tr. cinehon. eo J 



M. ft. sol. 
S.— A teas 

curie symptoms appear. ^^^^ ^^ ^^^ ^^^^^ ^ ^^^^^ 



S. — A teaspoonful in water 
every four hours until mer- S.-A teaspoonful in water 



A urethra or bladder that has once spread a disease 
of this kind, through disturbance incident to proper 
urethral instrumentation, should be dealt with care- 
fully. 'No instrument should be used for a time, if it 
is possible to dispense with it. If it is imperative, 
every detail of cleanliness should be observed. 

Sulphate magnesia, in small doses, given to free 
purgation, if condition will admit, and digitalis, in 
rather heroic doses, when there is suppression of urine, 
such treatment that will dispose of effete urinary pro- 
ducts is indicated. 



72 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

Hot poultices, friction and net cups over the kidneys 
are of service. If uraemia is feared, or present, care- 
fully admmistered hypodermic injections of muriate of 
pilocarpine as a diaphoretic, hot vapor baths, sulphonal 
for the nervousness, brandy, milk, meat juice, pure 
air, and that general treatment appropriate to divest- 
ing the economy of a poison, and substituting in its 
stead healthy blood. Should abscesses form, the}^ 
should be opened ; should the bladder fail to properly 
drain itself, a perineal drain should l)e estabhshed, and 
free antiseptic washings employed. 

Hygiene of the Urinary and SexuaJ Organs. 

A very important feature in the management of all 
urinary and sexual diseases is the knowledge and ob- 
servance of their hygiene. Without regard for this, 
the best directed efforts may fail in purpose. This 
subject, then, will be referred to many times in the 
chapters that will follow. 

The term Hygiene, in its usual application, carries 
with it a sense of good food, pure air, cleanliness, 
rational exercise and those many matters essential to 
the promotion of well-being generally. While sexual 
and urethral hygiene mean no more than this, yet, to 
have its influence bear upon these areas, it is necessary 
that recommendations in this situation be specific. It 
is a matter of comparative ease to have the urinary 
organs obey our wishes, while much difliculty, at 
times, confronts us when we undertake the regulation 
of the sexual appointments. Excess of acid and the 
presence of crystals in the urine can be overcome by the 
administration of bi-carb. of potash, ten to twenty 
grains in water three times a day, or some form of 
alkali. In fact, many of the unnatural and disturbing 



hygie;ne; of the; urinary and sexual organs. 73 

principles found in the urine can be prescribed for 
with reasonable satisfaction. Its quantity may be 
regulated as well as the intervals of micturition. 

The skin should be sponged and frictioned, the 
bowels should be opened, the diet light, nutritious and 
digestible ; alcohol, malt, tobacco, acids and stimulants 
generally should be avoided. The sexual organs, how- 
ever, being more or less dependent upon the brain for 
rest, are much more difficult to master; to advise 
against lascivious thoughts may only mean a more 
active consideration of such subjects; this centre is 
beyond control, hence the great difficulty in having 
that purity of act and will necessary for sexual repose. 
Proper association, pure literature and a higher morality 
will add much in this direction. The use of substan- 
tial doses of potass, brom., thirty to forty grains in 
water, three or four times daily, may conduce to quiet. 
Camphor mono-brom., one to five grains ; sulphonal, ten 
to fifteen grains ; chloral hydrate, five to twenty grains, 
and other members of this class of drugs may be em- 
ployed with advantage. When the sexual make-up 
has been once set in motion it goes on unceasingly — 
nothing will stay it. Proper relations with woman is 
the only way satisfactory relief is to be had. Inter- 
course, then, at appropriate intervals, with one's wife 
is advocated, except those conditions attended by active 
inflammation. 

Foreign Bodies in the Urethra. 

Through a perversion of the sexual dictate, there are 
many adults who find pleasurable excitement by toying 
with their sexuals ; smooth bodies, like a catheter, bead- 
headed pins, the ivory-tipped umbrella rib, hair-pins, 
slate pencils, pens and the like are introduced into the 
urethra. Occasionally control is lost and such bodies 
pass beyond the reach of the sufferer. 



74 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

Children frequently introduce gravel, beads, beans, 
shot, etc., into the meatus, and are unable to produce 
them. 

Surgeons occasionally lose a part of an instrument, 
or a i^ledget of cotton, in the canal — this latter occurred 
to the author while making an application to a lesion 
through an endoscope ; a filiform bougie was made to 
engage it, and effected its removal. 

Old men Avho live a catheter life, on account of 
prostatic disease, lose a part of their instruments ia the 
urethra. The treatment for such conditions is regu- 
lated by the character of the body that is confined ; if 
a bean, bead, pledget of cotton, or any body without 
angles or rough surface, they may pass out during the 
act of micturition. Bodies, like parts of catheters, slate 
pencils, etc., may be supported from behind, and so 
manipulated and coaxed that they will present at the 
meatus. A pair of urethral forceps may be used with 
effect. 

Fig. 22. 




BLEES-MOORE INSTRUMENT CO 



It may become necessary to open the urethra, which 
can be done in the pendulous or deep portions ; I think 
it better to always do so through the perineum, and 
either introduce an instrument through such an open- 
ing and push the body forward, or introduce the in- 
strument at the meatus and extract the body at the 
new opening. 

I have never seen a fistula, or damage in this sitaa- 
tion follow a clean operation. Stones form in the 



FOREIGN BODIKS IN THE URETHRA. 



urethra, and either pass out; ulcerate their way out, at 
times leaving behind a fistula, or require removal by 
surgery. 

It is well to advise against pushing any body what- 
ever into the bladder, for when once there the founda- 
tion for the formation of stone about it is established, 
together with that long train of ills following irrita- 
tion, sepsis and degenerative changes. 



CHAPTEE lY 



URETHROSCOPY OR ENDOSCOPY— DISEASES OF THE URETHRA- 
INFLAMMATION OF THE URETHRA— SIMPLE URETHRITIS— 
BASTARD GONORRHCEA- SYPHILITIC URETHRITIS— TU- 
BERCULAR URETHRITIS — GONORRHOEAE URE- 
THRITIS— ANTERIOR GONORRHCEA— POSTE - 
RIOR GONORRHCEA— URETHRAL IRRI- 
GATION AND INJECTION— GLEET 
—RELAPSING GONORRHOEA. 

By urethroscopy or endoscopy is meant an examina- 
tion of the urethra with the eye, aided by a class of 
instruments and devices, called urethral endoscopes, of 
which there are many patterns. The entire canal can 
l)e inspected with more or less satisfaction. Diseased 

Fig. 23. 




BLEES-MOORE INSTRUMENT CO. 

Koltz's endoscope. 
Fig. 24. 




BLEES-MOORE INSTRUMENT CO. 



Otis' endoscope. 

areas can in this way be located, differentiated and 
treated. Famiharity with such instruments and much 
practice is essential to successful work. I have found 
satisfaction from the use of many instruments. Figs. 
23 and 21 are simple and convenient ; with them the 



URETHROSCOPY OR ENDOSCOPY. 



posterior portions of the pendulous urethra may be 
examined, diagnosed and treated. Fig. 25 is ap- 



FiG. 25. 




BLEES-MOORE INSTRUMENT CO. 

Tilden Brown's, without speculum. 
Fig. 26. 

Tu 




BUEES-MOORE INSTRUMENT CO. 

Leiter's pan electroscope. 



IDlicable for lesions in the anterior urethra. Fig. 26 
represents Leiter's pan electroscope, an instrument 
that illuminates the canal most brilliantly by means of 



ge:nito-urinary surgery and venereai. diseases. 



electricity ; the other instruments here produced re- 
quire reflected light from a head-mirror. Fig. 27 is a 
new and useful invention ; the instrument is introduced 
Avith its desired tube, the meatus is pressed firmly 




BLEES-MOORE INSTRUMENT CO. 



Aero -urethroscope. 



about the shoulder of same ; by means of the bulb, the 
urethra is now gently inflated with air, in which con- 
dition it is very satisfactorily examined with reflected 

light. 

Method of Using. 

The instrument should be surgically cleansed, the 
urethra irrigated (and not in a high state of acute in- 
flammation). Carbolized glycerine should be used 
to anoint the instrument. In this condition the in- 
strument, with its blades closed, or obturator in place, 
is gently passed beyond the diseased area ; now the 
blades are separated, or its obturator removed, and 
slowly withdrawn, the eye being intent upon the 
changing disc as it presents at the end of the instru- 
ment, until that portion which is diseased occupies the 
field, at which time treatment can be made that is in 
keeping with the character of the disease, after which 



DISEASES OF THE URETHRA. 79 

the instrument may be removed. Should the deep 
urethra be the seat of trouble, and it becomes neces- 
sary to engage the longer instrument, great caution in 
having straight bodies pass, and make straight the 
curved portion ; this can be done without damage or 
much pain. It is my custom to apply fifteen drops of 
a five per cent solution of cocaine with a deep urethral 
syringe to this part of the canal prior to its invasion 
with such instruments. Here, too, hemorrhage is 
likely to retard the work and many pledgets of cotton 
will be required to put the part in proper form (care 
should be exercised lest the cotton be lost in the ure- 
thra) . Once every four to eight days is as often as 
the operation is required. 

Diseases of the Urethra. 

This shut canal, lined with mucous membrane, may 
become diseased in a great variety of ways. Any 
agent introduced, capable of disturbing its function 
or nutrition, be that agent an irritating injection, acid, 
urine, or simple pus-producing micro-organisms con- 
ve^^ed upon instruments or otherwise, the result in 
any case may be inflammation. Should the urethra, 
then, take on inflammation due to the presence of any 
offensive material, even though this material be un- 
clean discharges from the vagina (free from gon- 
ococci) , and the disease acquired through the copula- 
tive act, such an attack is called acute simple 
URETHRITIS ; the pathology of such a disease is that 
of simple inflammation of mucous membrane. 

The incubative period of simple urethritis is very 
short; as a rule, tAventy-four hours to three days. The 
symptoms displayed are slight congestion of the me- 
atus with an uneasy sensation, later pus appears, there 



80 GENITO-URINARY SURGERY AND VENEREAI. DISEASES. 

is moderate pain during urination, and erections may 
be painful, generally, hoAvever, in a mild degree. The 
duration is ordinarily about ten days, but shorter and 
longer periods are frequently noted. The prognosis 
is good. 

The treatment consists in the observance of sexual 
and urethral hygiene, and the local use of astringent 
injections. 

No. 13. No. 14. 
^. — Liq. plumb, subaeet X'n. R. — Zinei Sulphas \„^ ^^^ 

r cici' /) So •■ 

Ext. pinus cann. (color- Alumen exsiecat J 

less) 3iii- Mucilago acacia gss. 

Aqua rosBB 5vi. Aqua destillata gviiss. 

M. ft. lot. M. ft. sol. 

S. — Inject three times daily. S. — Inject three times a day. 

No. 15. 

I^. — Acidum tannicum gr. xxx. 

Glycerinum "^iv. 

Aqua destillata - 5vi. 

M. ft. sol. 
S. — Inject three times a daj'. 

Almost all the mineral and vegetable astringents 
used in a mild strength are serviceable. In fact, such 
an attack will recover without local treatment at all, 
but not so surely and promptly. 

Owing to the existence of simple acute urethritis, 
and its strong resemblance to acute gonorrhoeal ure- 
thritis, the drug clerk has become a popular prescriber. 
The people themselves (especially young men of the 
world) have learned to prescribe by passing their cher- 
ished prescriptions among their unfortunate friends 
and thereby become the recipients of much praise. For 
this reason, too, the much extolled and self-lauded 
patent medicines (guaranteed to cure gonorrhoea in 
three days, etc.) still hold their places upon the shelves 
of the apothecary and continue high in the esteem of 
many. 



BASTARD GONORRHCEA, SYPHILITIC URETHRITIS. 81 

Bastard Gonorrhoea, or Sub=acute Simple Urethritis, 

is a low grade inflammation of the urethra, dependent 
upon a peculiar susceptibility of the urethra to take 
on disease, which is often on account of damage 
done the part by previous disease. The usual his- 
tory offered for such an attack is the acknowledgment 
on the part of the patient of having had previous ure- 
thral trouble. More frequently, that the urethra has 
been the source of extensive and prolonged disease 
and annoyance. As a rule, such sufferers are .intem- 
perate and excessive in all their habits. You will learn 
that following a debauch, including indulgence in 
wine, lunches, and women, the patient detects smart- 
ing and a muco-purulent discharge from the meatus 
upon arising the folloAving morning. This condition 
will constitute the disease so far as its acuteness is 
concerned, and there may or may not be found gono- 
cocci upon microscopical examination. Sexual and 
urethral hygiene, together with mild astringents, will 
soon right the condition, after which the urethra should 
be explored, when there will be found a lesion, either 
stricture, congested or ulcerated areas, that is respon- 
sible. Appropriate treatment directed to this under- 
lying cause will restore the integrity of the canal and 
prevent future occurrences. 

Syphilitic Urethritis, 

a form of urethral inflammation, due to the presence 
of a syphilitic lesion (either primary or a later expres- 
sion) , is occasionally encountered. 

If chancre becomes established in the urethral canal, 
its presence can be detected by its cartilaginous hard- 
ness, the character of the discharge (which is thin, 
serous or bloody, some pus, or a mixture of the 



:82 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

three). Little pain attends such a condition. The 
history of the case is important in reaching a diagnosis ; 
the glandnlar development and secondary manifesta- 
tions may hecome necessary before the real type of 
disease is» assured. If later syphilitic lesions become 
responsible for a urethritis, the history, character of 
the discharge and the endoscope will effect a diagnosis. 
Treatment in either should be the employment of anti- 
syphilitic measures internally, and local antiseptic irri- 
gations and washes. 

Tubercular Urethritis. 

Tuberculosis occasionally locates itself in the urethra, 
and there occasions inflammation, in consequence of 
destructive changes. The subjective symptoms are in 
keeping with the lesions and their situation, which are 
rarely extensive ; the discharge frequently resembles 
that due to syphilitic urethritis. The diagnosis will be 
made by the history, endoscopic appearance, general 
condition and the detection of the tubercle bacilli. The 
treatment is general, chmatic and local. 

Gonorrhoea! Urethritis. 

Literally, the term gonorrhoea is faulty, meaning, as 
it does, a flow of semen. It is accepted, however, and is 
synonymous with Clap, Blennorrhoea, Blennorrhagia, 
Specific or Infectious Urethritis. 

While the description and treatment of this disease 
has been assigned to its present position in this chap- 
ter, at the same time it is perhaps the foremost and 
most important matter that engages the Genito- 
urinary Surgeon, and is profoundly interesting to the 
Abdominal Surgeon as well. Attached to this disease 
is an antiquity as ancient as the history of man. The 



GONORRHCEAL URETHRITIS. 



83 



Bible unquestionably makes mention of the prevalence 
of such a disease. The fifteenth chapter of Leviticus 
affords a very clear account of it. When gonorrhoea 
(as we accept it) appeared for the first time, and under 



Fig. 28. 




Gonoeoeci of Neisser. 



what circumstances, no man of the present century 
can positively say, nor is it reasonable to believe that 
our knowledge in this direction will ever be complete 
(notwithstanding the beautiful theories of the evolu- 



84 GENITO-URINARY SURGERY AND VENEREAL DISEASEvS. 

tionists and the diligent researches already made). 
But what concerns ns most is the study and under- 
standing of the disease that we have about us to-day. 
Gonorrhoea is an acute, contagious, specific, inflam- 
matory disease of the mucous membrane of the urinary 
and genital tracts ; this disease may also involve the 
mucous membranes of the eye and rectum ; it is like- 
wise asserted, but not clearly proven, that the ear, 
mouth and nose may become the seat of gonorrhoea! 
disease. While I have not seen gonorrhoea in these 
two situations, yet I can see no reason why they may 
not acquire it under favorable conditions. Gonorrhoea 
is due to the invariable presence of the gonococcus of 
^eisser, notwithstanding the volumes holding a differ- 
ent view upon this feature of the disease. For several 
years its etiology has been the subject of debate, and 
only recently has the science of bacteriology given to 
the world the unmistakable fact of its bacterial origin ; 
to-day pure cultures are grown and the last link in the 
chain of evidence in this respect is produced. Any 
urethritis dependent upon or presenting this form of 
germ (Fig. 28) can be called gonorrhoea, and a ureth- 
ritis that (after careful and repeated microscopic ex- 
amination) fails to display this element, no matter how 
severe, how protracted, or how com]3licated it may be, 
is not gonorrhoea. A gonorrhoea may lose its specific 
characteristics and become a non-sjDecific urethritis, 
or it may lead to an injury of some part or parts 
that will continue the inflammation long after the orig- 
inal disease has passed. Such a state is not gonor- 
rhoea, but a post-gonorrhoeal condition ] in a word, it 
is gonorrhoea only when the specific micro-organism 
exists, or when a given discharge w^ill produce a gon- 
orrhoea when planted upon favorable soil. 



TUBERCULAR AND GONORRHCEAL URETHRITIS. 85 

A simple urethritis, acquired in any manner whatso- 
ever, will never become a gonorrhoea. The diagnosis 
of gonorrhoea at times becomes a matter of the utmost 
difficulty, and greatest importance ; difficult on account 
of the many subjective and clinic features common to 
the non-specific inflammation, and the negative' results 
of the microscope. The healthy urethra is known to 
present diplococci, bearing so strong a resemblance to 
the gonococci, that at times it is impossible to decide 
between them. It is often of great importance to know 
the truth, appreciating, as we do, the circumstances 
under which urethral disease is presented. Often it is 
the surgeon's attitude in such situations that main- 
tains the integrity of a household, or forever wrecks 
the future of a family. Many times have I put 
this knowledge to valuable use. Women are sus- 
picious and jealous creatures ; there are few, indeed, 
who regard man as possessed of virtue, if men 
were only so good in this sense as the concensus of 
feminine opinion vote them, there would indeed be 
little virtue in the land. Women with a discharge 
often believe themselves the victims of venereal disease, 
due to their husband's perfidy, and come to the doctor 
for verification of their views and for advice. Hus- 
bands occasionally present themselves to the physician 
with a discharge that they believe to be gonorrhoeal, 
and suspect their wives of infidelity. 

Young men contemplating matrimony are anxious 
about their urethral disease, and apply for advice. 
Gonorrhoea is not a blood or constitutional disease, in 
the usual sense, though some complications seem to 
indicate as much ; yet, as a distributor of disease and 
discontent, as a despoiler of sexual tone and morals, 
this disease holds a prominent rank. It is stated by 



so GENITO-URINARY vSURGERY AND VENEREAL DISEASES. 

good authority (to whose views I say amen), that on 
account of its direct and remote consequences, more 
victims are yearly sent to their last resting places on 
account of gonorrhoea than by syphilis. 

Indeed, it would Ije difficult to overestimate its 
seriousness ; the more intimate an acquaintance one 
has with it, and the more diligence displayed in its 
management, the greater becomes our respect. 

The element that is responsible for gonorrhoea can 
usually be detected, and with comparative ease ; the 
method of staining and examining is simple, the in- 
struments are not expensive. 

A drop of gonorrhcx'al pus, free from extraneous 
matter, is received and spread upon a glass slide, a 
second slide is pressed firmly upon this 'film of pus, 
the two glasses are slipped apart, and there is upon the 
surface of either a proper display of the material. 
Such a film is now permitted to dry in ar clean atmos- 
phere for about five minutes, it is then passed rather 
quickly through the flame of an alcohol lamp (pus side 
up) three or four times, (which latter fixes the specimen 
to the slide) apply to the specimen thus fixed sufficient 
stain (which may be an aqueous solution of methyl 
violet, methyl blue, gentian violet, Victoria blue or 
most any of the blue analine stains) to completely 
cover the specimen. Continue the application of the 
stain for about three minutes, when the slide is tilted 
and the stain runs off, a gentle stream of cold, pure 
water is permitted to wash aw^ny the excess of stain 
from the specimen, when it should be carefully dried 
and mounted with Canada balsam. 

A microscope with a magnifying power of not less 
than 500 diameters (a higher power is better, the oil 
immersion best) Avill reveal the organisms. From 



PATHOLOGY 



(Fig. 28) a fair idea of the form and arrangement of 
the o'onococci can be had. It will be observed that 
the arrangement is in pairs, fours, etc., as opposed to 
chains, groups and clusters. It is the arrangement 
especially that is characteristic of the organisms. 

Pathology. 

An understanding of the pathology of gonorrhoea 
affords a rational explanation for the symptoms dis- 
played by it. During the copulative act (usuallj^) 
there is lodged in the male urethra in the neighbor- 
hood of the meatus a greater or lesser amount of the in- 
fectious material. The gonococci at once engage 
themselves, searching for food and preparing a place 
for residence and propagation. In accomplishing this 
their presence disturbs the normal nutrition of the part 
to an extent that there is a local congestion, the ves- 
sels becoming larger and their walls thinner, allowing* 
an exudation of the white blood corpuscles. These 
organisms, after invading the epithelium of the mucous 
membrane, locate and attack the deeper connective 
tissue. It is due to the intrusive presence of these el- 
ements that there is congestion , followed by exudation, 
emigration and proliferation of the plastic elements of 
the parts. In this way the degenerated or necrosed 
white blood cells appear as a discharge of pus, carry- 
ing with it the infectious germ. 

The prognosis in gonorrlKPa should be guarded, 
and made favorable only when the patient has con- 
sented to live true to the advice and treatment that 
is indicated. Under such terms, I believe he can 
with reasonable security be promised a cure in from 
one to ten weeks ; otherwise it would be difficult to 
forecast his future. 



88 GKNITO-URINARY SURGERY AND VENEREAL DISEASES. 

The incubative period of gonorrhoea is rather well 
fixed at five days, occasionally as short as two, rarely 
a^ late as ten. 

The symptoms of gonorrhoea are measured by the 
parts involved and the resistance offered by the in- 
dividual. 

A train of symptoms common to the average at- 
tack, begins about the fifth day following exposure, 
with a tingling, itching sensation at the meatus and 
uneasiness upon passing water, this is soon succeeded 
by a smarting or burning pain. An inspection of the 
parts will now show a congestion of the meatus bathed 
in a slight serous discharge, the appearance of the 
meatus will soon deepen into an intense red, it will be 
puffed, everted and bathed with a heavy creamy dis- 
charge of pus. This inflammation starting at or near 
the meatus, proceeds slowly backward, steadily in- 
creasing in severity as it goes, for eight to twelve 
days, when the entire pendulous portion of the urethra 
is attacked; this period of the disease can well be 
called the Adyaxcing or Ixcheasixg Stage, it is now 
that the entire organ takes on a much disturbed appear- 
ance, the local sexual centers become aroused, and the 
disturbance maintains an activity of these nerves, ren- 
dering the nights sleepless on account of persistent 
and intensely painful erections, nocturnal emissions 
occur frequently and add to the distress. The mucous 
membrane of the urethra now loses its elasticity, the 
corpus spongiosium urethrse is filled with an exudate, 
preventing its expansion and elongation along with the 
corpora cavernosa during erection, eliciting pain and 
rendering that downward curving of the penis called 
Chordee. The lymphatic vessels may become inflamed, 
tender, and appear as whip-cords under the skin. The 



POSTERIOR GOXORRHCEA. 89 

lymphatic glands occasionally become enlarged and 
painful. Arduor urinae (or painful urination) is now 
at its zenith, such a state is usually maintained for a 
week, which period is called the Stationary. 

The symptoms will now begin to subside usually in 
an inverse order of their onset. The discharge be- 
comes thinner, erections less painful, urination bear- 
able until the morning drop of pus is the only evidence 
of the disease ; usually two weeks are required until 
this decreasing or dechning period is ended. 

Posterior Gonorrhoea. 

Should gonococci gain access to the urethra beyond 
the triangular ligament, all those important structures 
found in the prostatic urethra may become infected and 
there Avould be a posterior gonorrhoeal urethritis. 
Every opening found here can become the seat of 
gonorrhoeal disease, and from the nature of this situa- 
tion it is readily seen how this disease can become re- 
sponsible for prolonged and extensive suffering, and 
damage that may be permanent. 

By this same process of invasion the disease can 
travel backward into the bladder, up the ureters and 
attack the kidneys ; it may enter the ejaculatory ducts, 
invade the seminal vesicles, pass through the vasa- 
deferentia, epididymes and reach the testicles, lighting 
up in its progress an inflammation of the several parts 
invaded, and leaving in its wake damage proportionate 
to its severity. My experience is that once in five 
the disease passes beyond the pendulous urethra, that 
treatment promptly applied does much to limit its 
duration, its severity, and maintain it within safe 
bounds. 



90 ge:nito-urinary surgery and yenereai. diseases. 

Treatment of Gonorrhoea. 

It has been shown that this disease has engaged the 
attention of medical men for many ages. During 
this time, there has been prepared an endless list of 
agents, presumed to be of service in its treatment. 
Many remedies have (for short periods) been looked 
upon as specifics and as many disappointments have 
followed. Each case then is to be prescribed for upon 
its merits. There should be no stereotyped prescrip- 
tions, no set plan, 

Observance of sexual and urethral hygiene is al- 
ways a conspicuous feature of any treatment. As 
previously indicated, gonorrhoea can be conveniently 
considered as possessing three stages, the Increasing, 
the Stationary and the Declining and rational treatment 
vs^ill be that which best meets these conditions. 

The Abortive Treatment. 

Should a patient apply within twelve hours of the 
beginning of an attack of gonorrhoea, it is my rule to 
paint the meatus and the first one-half inch of the 
urethra with a twenty per cent solution of cocaine, 
introduce a short speculum (Fig. 29), with a camel's 

Fig. 29. 




BLEES-MOORE INSTRUMENT CO. 



hair pencil, or cotton pledget, apply to the first one-half 
inch of the urethra a solution nitrate of silver (thirty 
grains to the ounce of distilled water), such an appli- 
cation may succeed by either washing away, or de- 
stroying the gonococci, or by substituting a violent 
simple, for a specific inflammation. 



TREATMENT OF GONORRHCEA. 



91 



Should gonorrhoea continue after the subsidence of 
this inflammation it is well to abandon the hope of 
abortion. Prolonged and free daily irrigations of hot 

Fig. 30. 




Irrigation of the urethra. 

1-10,000 bichloride of mercury solution, hot boraeic 
acid solution, or a solution permanganate of potash, 
or zinc 1-3000 with a Kiefer nozzle, as illustrated by 



92 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

Fig. 30, is recommended for abortion of gonorrhoea. 
With the permanganate sohition I have had much 
satisfaction. I have aborted a very small percentage 
only, but often the inflammation has been so modified 
that the attack but slightly resembled the usual. 

My experience with bichloride of mercury in various 
strengths, used either as an irrigation, or anterior hand 
injection, has been disappointing. I have not only 
failed to get satisfactory returns, but almost invariably 
I intensify the grade of inflammation ; in other words, 
I know no more prompt and sure way of converting a 
mild gonorrhoea into a violent than to apply this drug- 
in appreciable strengths. 

"When abortion of gonorrhoea fails, or when the case 
is one unsuited to that form of treatment, the sys- 
tematic form of treatment is to be employed. The pa- 
tient should first be impressed with the value of sexual 
and urethral hygiene and then instructed in the art of 
making an injection. 

Urethral Injection and Irrigation. 

Medication of the urethra, by means of the anterior 
hand injection, with what is known as a penis syringe 

Fig. 31. Fig. 32. 




Fig. 33. 



BLEES-MOORE INSTRUMENT CO. 



or an irrigator, is an operation worthy of understand- 
ing. When an injection is prescribed for a patient, it 
is important that it be used correctly. N^o matter how 



URETHRAL INJECTION AND IRRIGATION. 93 

efficient the remedy may be, except it be inteligently 
applied it Avill fail to accomplish what is expected. 
Many times a discharge has continued unnecessarily 
when all else had been well done, and the in- 
jection wasted through improper application. The 
syringe itself should be prescribed. A size should be 
had that will comfortably fill the urethra, with a point 
that will snugly fit the meatus. Figs. 31 ^ 32 and 33 
represent instruments that meet these indications. 

The urine should be voided, the syringe completely 
filled, the lips of the meatus separated, the point of 
the instrument inserted, and the contents gently dis- 
charged into the canal ; there should be no leaking 
from the sides and no waste of the injection ; when 
the syringe has been emptied it is slowly removed, 
making the meatus hug it closely, and still not a drop 
of the injection is permitted to escape ; the injection is 
retained, with this slight lateral pressure, for a few 
seconds and is then allowed to escape slowly. 

Irrigations are made in a variety of ways. Fig. 30 
illustrates a very convenient method, showing the ap- 
plication of the Kiefer nozzle. By placing the finger 
over the outfloAv arm for an instant the urethra may 
be stretched and irrigated at the same time. 

During the advancing stage of gonorrhoea, it is the 
custom of many to withhold all local treatment. It is 
claimed that prior to the declining period (or rather, 
so long as the trouble appears acute) injections are a 
disadvantage ; this class recommend injections and 
local measures late in the disease. There are those, 
too, who take a more extreme view and believe the 
disease to be strictly self -limited and do but little in a 
direct way toward treatment. The basis for the belief 
in these positions is anything but scientific, nor are 



94 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

such fancies strengthened by the results of this prac- 
tice ; my patients have certainly done better with treat- 
ment than without and have done better when local 
measures have been prescribed. I have labored in this 
field without favor or prejudice, with but one end in 
view, and at this moment I am convinced most posi- 
tively of this fact. If the situation of the patient will 
allow, irrigation of the parts with a permanganate, or 
some other suitable solution, three times a day, this will 
meet all requirements so far as local medication is con- 
cerned, otherwise the hand injection will be necessary. 
N^o injection should be continued when intense burn- 
ing or pain is produced by it, or when from its irritat- 
ing nature the disease is aggravated ; and no injection 
should be dropped Avhen comfort and disappearance of 
symptoms attend its use. The strength of an injec- 
tion should be determined by its effect. There is a 
belief that prevails extensively, especially in the minds 
of the laity, that it is injurious to allay inflammation 
too suddenly, or cure a clap too quick. This, of course, 
is erroneous. A solution in one situation may not be 
applicable in another. 'Not that there is difference in 
the remedies used or the character of the disease to be 
treated, but on account of the difference in individuals. 
A remedy that will produce a distinct sensation of 
warmth, without burning, is desirable. Weaker solu- 
tions are indicated in the advancing stage, than in the 
stationary or declining. Antiseptics and astringents 
are the remedies used in injections. It is bad surgery 
to fly from one prescription to another or to be con- 
tinually modifying the plan of treatment without 
especial reason. It shows a lack of confidence in one's 
ability and is demoralizing to the patient. Should 
the plan of treatment selected for the increasing 



URETHRAL INJECTION AND IRRIGATION. 



95 



stage modify its severity and shorten this period, 
the same plan will be servicable during the stationary, 
and should this period in turn be shortened, the same 
plan should be continued into the decreasing period 
and on, until the disease is terminated. A clap should 
be treated for at least ten days after the disappearance 
of every symptom. I have many times recommended, 
upon the cessation of all symptoms, the continuance 
of the treatment as before, except Avhen a syringefull 
of the medicine has been taken from the bottle, add to 
the bottle a like quantity of water. 

The prescriptions here presented are for the most 
part those that have been well tested and approved. 
Many of the novelties are not mentioned. 



No. 16. 

I^. — Zinci permangan gr. iiii. 

Aqua destillata §vi. 

M. ft. sol. 
!S. — Inject three times daily. 



Xo. 17. 

R.— Zinci sulph ^ss. 

Ext. hydrast. fld oiiii- 

Aqua destillata 5viiss. 

M. ft. sol. 
S. — Inject three times a dav. 



Xo. 18. 

R. — Liq. sodpe ehlorat^B 5ss. 

Aqua destillata , gvst 

M. 

S. — Inject three times a day. 



No. 19. 

I^. — Bismuthi subnit '^i. 

Acidum boricum gr. xl. 

Coeain83 muriat gr. vi. 

Aqua rosee giv. 

M. ft. lot. 

S. — Inject four to six times 
daily. (Useful in the early 
and highly inflamed state of 
urethral disease.) 



No. 20. 
I^. — Liq. plumb. subacet-.5iii. 

Ext. opii aquos gr. x. 

Aqua camphorge.. .. 1 

Aqua destillata )^^ '^n- 

M. 
S. — Inject three or four 
times a day. (A mild injec- 
tion.) 



96 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

No. 21. No. 22. 

^. — Zinci sulpho carbolat gr. x. I^. — Zinei sulph ^ 

Ext. piniis cann. (color- Plumb, acetat V aa 9i, 



less) ^ss- 



Alumen exsieeat 



Aqua destillata Svss. Mueilago acacias gss. 



M. 



Tr. catechu 3^ii- 

S.-Inject three times a day. ^'^""^ destillata, q.s.fl..5viii. 

S. — Inject three times daily. 

Xo. 23. No. 24. 

^. — Acidum carbolicum ...TIJ xx. I^. — Argenti nitras gr. i. 

Glyeerinum .^ss. Aqua destillata ^wi. 

Aqua destillata o^ss. M. ft. sol. 

M. S. — Inject three times a day .- 
S. — Inject three times daily. 

No. 25. 

I^. — Argonin gr. 5-50 

Aqua destillata 5iv. 

M. ft. sol. (by heat). 
S. — Inject three times a day. This remedy (a silver 
salt) is, perhaps, at this moment the most extolled. I 
have had much satisfaction from its use early in gonor- 
rhcea. 

To even mention in this connection the many reme- 
dies that have been nsed as injections in the treatment 
of gonorrhoea wonld be (figuratively speaking) to in- 
corporate the materia medica in the text. The list 
that I have submitted, however, will be found suffi- 
ciently complete for the prescriber's purpose. The 
newer remedies that are included are those that I have 
used, though in some instances to a limited extent. 

The first list will include those agents that have 
long been prominent as anterior injections. 

The second list will embrace the newer remedies 
that may be used in the same manner. 

The third will be those substances recommended for 
irrigation or retro jection. 

The fourth will be such as may be used in ointment 
or suppository form. 



URETHRAL INJECTION AND IRRIGATION. 97 

The fifth will be the usual remedies for deep or pos- 
terior urethral medication. 

List No. 1. 

staple remedies. 

Boric acid, 5 to 10 grains to the ounce of water. 

Carbolic acid, 1 to 5 minims to the ounce of water. 

Tannic acid, 2 to 5 grains to the ounce of water. 

Alum, dried, 2 to 5 grains to the ounce of water. 

Silver, nitrate, )^ to 1 grain to the ounce of water. 

Bismuth, sub nitrate, 5 to 20 grains to the ounce of water. 

Sol. chlorinated soda, >^ to 2 drams to the ounce of water. 

Creosote, 1 to 5 minims to the ounce of water. 

Sulphate of copper, js to 1 grain to the ounce of water. 

Fl. ex. ergot, X ^^ 1 dram to the ounce of water. 

Fl. ex. krameria, X to 1 dram to the ounce of water. 

Fl. ex. hydrastis, Yz to 2 drams to the ounce of water. 

Fl. ex. hamamelis, >4 to 1 dram to the ounce of water. 

Fl. ex. nutgall, X to X dram to the ounce of water. 

Bichloride of mercury, ]i to Yz grain to the ounce of water. 

Tr. kino, Yz to 1 dram to the ounce of water. 

Sol. subacetate of lead, diluted. 

Ext. of opium, aqueous, 1 to 5 grains to the ounce of water. 

Acetate of lead, 1 to 5 grains to the ounce of water. 

Potassium, chlorate, /^ to 3 grains to the ounce' of water. 

Potassium, permanganate, ^ to 2 grains to the ounce of water. 

Sodium, chloride, 1 to 10 grains to the ounce of water. 

Zinc, chloride, V20 /to Vs grain to the ounce of water. 

Zinc, sulphate, 1 to 5 grains to the ounce of water. 

Zinc, acetate, 1 to 5 grains to the ounce of water. 

Zinc, sulphoearbolate, 1 to 5 grains to the ounce of water. 

Iodoform, 5 to 30 grains to the ounce of water. 

List No. 2. 

newer remedies useful in gonorrhoea in the form of injection. 

Author's Estimate. 
Antipyrine, 5 to 10 grains to the It • st - ^^ x.- 

ounce of water. | Is a very inferior application. 

llumnol 3 to 10 o- -a "us t tl f "^ useful remedy, but falls short 
,.,.^2r. r.f „ ^^-^ ^^ ^ *^ ^^s of the extravagant claims made 

ounce or water. p -^ 

Gallobromol, 2 to 10 grains to the f An excellent remedy in the early 
ounce of water. \ period of gonorrhoea. 

-TV ^ 4- 1 o + - • • ■ r Used in two cases only: its more 

^f r. -l' ' ^^^"""^ """ '^'''" extended use was not warranted by 

y its action. 



98 GKNITO-URINARY SURGERY AND VENBIREAIv DISEASES, 

n T o 4. o • i. +, f Is very similar in action to car- 

Creolme 2 to 8 grams to the I ^ ^ 

ounce of water. | ^^ ^ p^^,.^^ ^.^^ .^^ i 

Lysol, 2 to 8 grains to the ounce ( Used in twenty cases, results in- 
of water. (.ferior to permanganate of potash. 

Ichthyol, 3 to 20 grains to the 1.,^'^^'^^^'^^^^^^'^' l^^ve found 
„ -^ ' *^ ^ it to be superior m some cases to 

ounce of water. | ^^^ ^^^^^ injections. 

Thallin, sulphate, 3 to 10 grains f j^ ^^^^^^^^ ^^ ^ ^^^^^^ 
to the ounce of water. I •- ^ 

-OT, . I/O.,/ -iiuT Seemed to be of service ; a more 
Pyoktanin, Vio to ^< gram to the ^^.^^^-^^ ^,, i^ necessary for an 
ounce of water. (opinion. 

Sozoiodol of zinc, 3 to 12 grains ( ^^^^^^ ^^^^ ^^^^ ^^ ^^^^ sulphate, 
to the ounce of water. (, ^ 

Pyridin, % to J4 grain to the f Often has a pronounced effect; at 
ounce of water. \ times, however, it fails completely. 

List No. 3. 

irrigations and retrojections. 

Fig. 34. 



BLEES-MOORE INSTRUMENT CO. 

Mitchell's soft rubber retrojector. 

To be used with the Kiefer nozzle, Fig. 34; or with Mitchell's soft 
rubber retrojector, Fig. 35. 

1. Hot bichloride of mercury, solution 1:20000 or 1:50000. The 
temperature of the solution at first should be 100^ F., gradually raised until 
the heat is complained of; at least half a gallon should be used at each sit- 
ting, which may be once a day. 

2. Permanganate of potash or zinc, in strengths varying from 1 :500 to 
1:5000, may be used in the same manner. 

3. Nitrate of silver, in strength of 1:20000 to 1:50000. 

4. The other drugs are alumnol, sulph. of zinc, solution chlorinated 
soda — all well diluted. 



urethral injection and irrigation. 

List No. 4. 

such remedies as may be used as ointments or suppositories 

in the urethra. 

Fig. 36. 



99 




CujDped sound. 
Fig. 37. 




BLEES-MOORE INSTRUMENT CO. 



Lewis' applicator. 

Ointments are applied with various devices. The cupped sound. Fig. 
36, is one of the oldest and best. The ointment is rubbed into the cups 
and the instrument, thus armed with medicine, is introduced in the usual 
manner. Useful in this department is Lewis' applicator, Fig. 37. 

The base for ointments is lanolin, vaseline or benzoated lard. The base 
for suppositories is cacao-butter; and the base for urethral bougies (or an- 
trophores) is gelatin. Iodoform, camphor, tannic acid, bismuth, sulphate of 
zinc, opium, boric acid, acetate of lead, nitrate of silver, powdered golden- 
seal; in fact, most any powdered drug that maybe indicated can be used. 

List No. 5. 

proper remedies for posterior urethritis. 

Fig. 38. 




BLEES-MOORE INSTRUMENT CO. 



Keyes' deep urethral syringe. 

The deep urethra frequently demands local treatment ; liquid applica- 
tions are made with the deep urethral syringe, Fig. 38; one or more drops 



100 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

as indicated, being applied to the diseased area once every third day, or 
oftener if necessary. 

Nitrate of silver, 5 to 30 grains to the ounce of water, is used oftener 
than any other agent. 

Sulphate of copper, 5 to 20 grains to the ounce of water. 

Sulphate of thallin, 5 to 20 grains to the ounce of water. 

Ichthyol, 5 to 50 grains to the ounce of water. 

Gallobromol, 5 to 10 grains to the ounce of water. 



In the internal treatment of gonorrhoea the drugs 
known as anti-blennorrhagics are made use of. The 
use of balsam of copaiba is almost universal ; it has 
played a conspicuous part in the treatment of gonor- 
rhoea many years, and is to-day highly esteemed. 
The flavor of this drug to many is intolerable ; it is 
indigestible and inelegant ; it is frequently responsible 
for gastric distress, diarrhoea, headache, dizziness, 
pain in the kidneys and a rash that resembles the 
eruptive fevei's, therefore its use should be watched 
and the dose guarded. What has been said of balsam 
of copaiba can be said of the oil of sandal-wood and 
the oil of cubebs, except there is no rash and less 
kidney irritation with these latter. Cubebs may be 
employed in one of several forms (the powdered 
berries, the fluid extract, the tincture, etc.) ; it is 
especially serviceable in the late period of gonorrhoea. 

Several very reputable pharmaceutical houses are 
preparing capsules of these three remedies, that in 
point of convenience have special claims. At times a 
combination of them seems to act better than when 
given singly. Turpentine may be cautiously prescribed 
in the late stage of the disease, one or two drops given 
three times daily. Tr. cantharides in doses of one to 
three drops acts favorably in the late period also. 
Exs. 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37, 
will afford an idea of construction. 



URETHRAL INJECTION AND IRRIGATION. 



101 



No. 26. 

^. — Bals. eopaibfe ,3ss. 

Pulv. acacife 5ii- 

Liq, potass o^^'S- 

01. menth. pip gtts. xii. 

Ext. pancreat. liq .^ii. 

Aquadestillata.q.s.ft.giv. 
M. ft. emul. 
S. — A teaspoonfiil in water 
after each meal. 



No. 27. 

I^. — 01. santal 5SS. 

Pulv. aeaci?e 3ii- 

01. einnam gtts. xii. 

Aqua pur giiiss. 

M. ft. emul. 
S.— A teaspoonful in water 
after eaeli meal. 



Xo. 28. 

I^. — 01. cubebfp .3^s. 

Pulv. acacia 5ii- 

Mua pur laa^ii 

Syr. aurantii cort J d^^. o^^- 

M. ft. emul. 

S. — A teaspoonful in water 
after each meal. 



No. 29. 

I^. — Potassiibrom 5"^'^- 

Tr. aconit gtts. xxxii. 

Ext. hyoseyam. fld..5i- 

]jiq. potassii cit gvi. 

M. ft. sol. 

S. — A teaspoonful in water 
every two or three hours for 
irritation of bladder and pain- 
ful nvination. 



No. 30. 



R.— Salol 



Ext. balladon. pulv ...gr. iii. 

Camph. monobrom gr. xii. 

M, ft. chart. No. xii. 
S. — One every four hours in 
water, to render the urine 
sterile and free from bacteria. 



No. 31. 

1^. — Tr. verat. viridi 1]] viii. 

Sodii brom 3i^'- 

Potassii bicarb 3^^"- 

Aqua einnam o"^"^^^- 

M. ft. sol. 

S. — A tablespoonful three 
or four times a day, to over- 
come excess of acid in urine, 
etc. 



No. 32. 

I}^.— Ext. kava kava fid gii. 

Acidum benzoicum 3ii- 

M. 

S. — Half a teaspoonful in a 
wine glassful of water after 
each meal. 



No. 33. 

Bi:.— Tr. cantharid ITl xxx. 

Tr. cubebse 5V. 

Tr. hyoseyam 3ss. 

Fl. ext. cascara ar 3^- 

M. 
S. — A teaspoonful in water 
after meals for frequent and 
painful urination. 



102 GENITO-UKINARY SURGERY AND VENEREAL DISEASES. 

No. 3-4. No. 35. 

R. — Thyroid extract gr. xxx. ^.. — Protonuelein gr. xxxvi. 

Ft. caps. No. XV. Ft. caps. No. xii. 

S. — One capsule four times S. — One capsule four to six 

daily. A useful remedy in times a day, for the same 

increasing resistance of the purpose as No. 34. 
tissues, thereloy limiting the 
spread of gonorrhoea. 

No. 36. No. 37. 

R.— Guaiacol Iljxxxii. ;Rt.— Guaiacol Tl>xx. 

Acidum salicylicum.gr. xxxii. Hydrastine gr. xxv. 

Glycerinum 51. Aqua destillata Sviii. 

Elix. cinchona o^u- ^^- ^^- ^<^1- 

M. ft. sol. S. — Inject three or four 

S. — A teaspoonful in water times daily, 
four times a day. Useful in 
all inflammatory conditions of 
the urinary organs. 

liubber bags, sold as gonorrha^al bags, and all 
wrappings of the penis during a gonorrha^a are inju- 
rions. The custom of applying cotton to the meatus 
for the purpose of collecting the discharge is bad ; (the 
first drop of pus cements the cotton to the meatus, its 
outer surface forms a crust and acts as a dam.) Free 
drainage is important, therefore a handkerchief, worn 
as an apron, or some similar dressing that will not re- 
tard the outflow of the discharge is desirable. 

There is much in connection with this disease and 
its proper management that is unfortunate. It is a 
rule that such patients are either 3^oung men, living at 
home, or married men ; in either instance they are 
forced to take such care of themselves as surroundings 
will admit. They do not make known their condition 
for fear of consequences. The medical attendant in 
these situations is forced to direct a treatment under 
great disadvantages. The first attack of gonorrhoea 
is usually the severest, and is the surest to disappear 
completely. 



GI.E15T. 108^ 

Gleet. 

With the usual termmation of an attack of gonor- 
rhoea is a mucoid discharge. The mere presence of 
this viscid material in the urethra, whether it be due to 
one cause or another, constitutes the condition known 
as gleet. There is an underlying cause for this symp- 
tom which may be a catarrhal state following gonor- 
rhoea, a congested spot or spots in the canal, an ulcer, 
stricture, etc. At all events a gleet is an indication of 
a chronic state, and the discharge (which may be the 
only evidence) , is usually slow to disappear. Astrin- 
gent injections and irrigations benefit the condition, 
and if the lesion be within the reach of such applica- 
tions, often gleet is cured. This stage of urethral 
trouble appears at a time when the patient is eager to 
be discharged; he is, therefore, restless, impatient 
and rebellious. This disposition on the part of the 
patient often induces the sympathetic physician to 
overtreat the case and the discharge is often the out- 
growth of such zealousness. 

In the face of a stubborn discharge, taxing one's in- 
genuity on one hand, and a distracted and unreason- 
able patient continually seeking a change of medicine 
upon the other, the attendant, (except he be of tranquil 
turn) is liable to err in this direction. 

Should such a discharge persist after diligent treat- 
ment for a period of two or three weeks, it is well to 
discontinue all local treatment for a time and observe 
the behavior. Should the trouble continue unchanged 
without local treatment, permit it to rest for about two 
additional weeks. Should the inflammation increase, 
return to the treatment. After the disappearance of 
gonococci from the discharge, it Avill be proper to 
search for the cause, Avhich, when found, may be 



104 GENITO-URINARY SURGERY AND VENEREAL DISEAvSES. 

treated as an ulcer, or as a stricture ; it will then be that 
the discharge will cease and the attack brought to an 
end. When it is impossible to locate the lesion, as is 
frequently the case, the use of the cold sound every 
third or fourth day may be r,esponsible for a cure. 
Should the lesion be in the deep urethra, two to five 
drops of tannate of glycerine, two to five drops of a 
solution of sulphate of copper (ten grains to the ounce 
of water), two to five drops of a solution of nitrate of 
silver (three to five grains to the ounce of water) ap- 
plied with a deep urethral syringe to the lesion, 
will be beneficial. 

The greatest care should be exercised in manipula- 
tions here wdien the discharge contains pus. Usually 
urethral trouble of this nature is confined to those ac- 
customed to the exercise of their genitals. I believe 
that the congested condition, incident to unaccustomed 
continence, is injurious. Sexual hygiene, under such 
circumstances, is a thing impossible; I, therefore, 
recommend copulation after the disappearance of the 
gonococci, and believe the condition is more amenable 
thereafter. 

In the treatment of gleet I have used iodoform, dry 
and in suppositories, boric acid, bismuth subnitrate, etc. 
The suppositories are irritating and inferior to injec- 
tions. It is generally recommended in the treatment 
of most urethral inflammations to render the urine 
slightly alkaline by the administration of some antacid 
like soda bicarbonate (fifteen to thirty grains) , potash 
citrate (fifteen to twenty grains), soda benzoate (five 
to ten grains) , etc. I prescribe such a remedy only 
when the urine is abnormally acid, and then in such 
quantities as will bring the acidity down to normal. 

Should the urine become alkaline I render it nor- 



REIyAPSING GONORRHCEA. 105 

mally acid, for the reason that the urethra tolerates 
best, and is at ease when it is subjected to contact with 
normal urine. I am convinced that in diseases of the 
stomach, bowels and like organs, their function is best 
performed, and in disease they assume a normal state 
•soonest when their environment is normal. N^ormal 
urine then is distinctly healing to a diseased urethra 
and for that reason alkalinity is undesirable, again 
Finger first called attention to the fact that the gono- 
cocci flourished in alkaline discharge. 

Relapsing Gonorrhoea. 

Attacks of gonorj-hoea frequently pursue a more or 
less regular order for a given period, the treatment 
prescribed may appear in every way equal to the con- 
dition, the discharge may disappear and the cure seem 
complete, several days after the abandonment of the 
treatment, the discharge may reappear, gonococci 
may be found and all the symptoms of gonor- 
rhoea develox^. Treatment now instituted may very 
soon return the parts to a state of relative health, when 
under like conditions another relapse will follow. It 
will be found that the urethra has been restored to 
normal except in one or more restricted areas, which 
latter may be an ulcer, an abscess of small size, an 
irregular space behmd a stricture or any condition that 
will harbor the gonococci and prevent their elimina- 
tion or destruction. These micro-organisms thus pro- 
tected, begin active work upon the cessation of the 
treatment, they encroach upon and invade new parts, 
and evoke a fresh attack in a way but little different 
from the original. Such conditions can be success- 
fully managed by reducing the disease to these hiding 
places, locate these secret retreats with a bulbous 



106 GENITOURINARY SURGERY AND VENEREAL DISEASES. 

sound, or an endoscoj^e and make direct application of 
a substantial solution nit. of silver (one drop of a 
twenty gr. to oz. sol.) Sounds maybe used in over- 
coming these irregularities of the canal in a way that 
injections and irrigations may reach the focus of in- 
fection. Care should be exercised that such instru- 
ments do not pass beyond the lesion and infect deeper 
structures. 



CHAPTEE Y. 

COMPLICATIONS OF GONORRHCEA— POST-GONORRHCEAL NEU- 
ROSES, LYMPHANGITIS, ADENITIS, ABSCESSES OF THE 
URETHRAL FOLLICLES, PERI-URETHRAL INFLAMMA- 
TION, COWPERITIS, PROSTATITIS, SEMINAL VESI- 
CULITIS, EPIDIDYMITIS, ORCHITIS, EPIDIDYMO- 
ORCHITIS, DEFERENTITIS, CYSTITIS, URE- 
TERITIS, PYELITIS, CONJUNCTIVITIS, 
GONORRHCEAL RHEUMATISM. 

An attack of gonorrhoea may run a regular course and 
the patient recover. The attack may have been mild and 
short throughout, and yet there may develop a neuralgia 
of the penis, testicle or other parts of the gentals that may 
be paroxysmal and severe; constant, or vague and indefi- 
nite. The pain may originate in the testicle, pass rapidly 
up the cord and on to the glans-penis. There may be 
nothing visible, nothing to determine the cause of such 
pain except the statement of the sufferer that he has suf- 
fered a recent attack of gonorrhoea. Micturition and erec- 
tion of the penis may be painful, there may be bladder 
irritation ; such a neuralgic state may persist and become 
the source of much worry and depression. 

In the absence of a visible cause the treatment should 
embrace a change of scene and circumstance, recreation 
and diversity, such tonics as will insure general improve- 
ment. The bromides, iron, arsenic, cannabis indica, 
gold, and assafoetida may be used. 

Lymphangitis. 

In the presence of a long fore-skin, gonorrhoeal or other 
forms of inflammation in this situation verv often induce 



108 



GENITOURINARY SURGERY AND VENEREAL DISEASES. 



an cedematous, boggy condition of the loose tissue of the 
prepuce (Fig. 39) ; this state is due to septic matter acting 
upon the superficial lymphatics, attended by an infiltration 



Fig. 39. 




Lymphangitis complicating Gonorrhoea. 

of the parts, and is vulgarily called bull-headed clap. Such 
disturbance may be so slight as will only attract notice ; 
there may be no pain or inconvenience, or so extensive as 



LYMPHANGITIS. 



109 



to cause great deformity of the part, predisi30sing to 
phimosis ; fever may run rather high and the general ap- 
pearance resemble an attack of erysipelas. 

The main lymphatic trunks may, in a like manner, be- 
come infected; they will display a sense of hardness 
throughout their inflamed portions, become several times 
their natural size and not be the seat of much pain. Those 
instances where the structures about the vessels become 
involved, giving rise to a peri-lymphangitis, there is pain 
on pressure, red lines are noticed, marking the course of 
the inflammation. These inflamed vessels, made so in 
this connection on account of the absorption of gonor- 
rhoea! products, may develop abscesses in their course 



Fig. 40. 




Abscess resulting from Inflammation of Lymphatics. 

(Fig. 40), or conduct sufficient material to the near-by 
lymphatic glands to cause their inflammation. Such an 
adenditis is usually not severe ; suppuration is not to be 
expected except the general health is poor. Should sup- 
puration occur, it is claimed by good authority that the 
pus is not auto-inoculable. This, I am quite positive, is 
not invariably correct. I have found gonococci here 
which, when planted upon the conjunctiva of a rabbit. 



110 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

gave positive results. When the gonorrhoeal element acts 
by disturbing a tuberculous process, and the breaking 
down is one other than gonorrhoeal , then one is safe in the 
premises, i. e., the pus is not capable of transmitting 
gonorrhoea. 

The treatment of the mild types of lymphangitis will 
consist in thorough cleanliness and the application of 
astringents. 

Exs. Nos. 38 and 39 may be used: 

No. 38. No. 39. 

B^. — Plumb, acet 5iss. R. — Unguent, zinci, ox. benz....5i. 

Ext. opii. aq gr. vi. Acidum tannicum 5i- 

Aqua destillata ^vi. M. ft. unguent. 

M, ft. lot. S. — Apply twice a day. 
S. — Apply on cloths or 
gauze three times a day. 

Should the oedema be excessive several punctures can 
b^ made, the exudate milked out and the part treated as 
above. 

Should the grade of inflammation be severer still, and 
there be fever and a peri-lymphangitis, put the patient to 
bed, apply hot compresses, open the bowels with sol. cit. 
magnesia, sulph. magnesia, or some saline cathartic. A 
few full doses of quinine or acetanilid for the fever, tr. iron, 
fifteen drops every four hours, nutritious diet, etc. Should 
abscesses occur, open early and treat surgically. It hap- 
pens at times that an extensive slough is the outcome of 
this disturbance, and any treatment prescribed should 
guard against such an end. Should the lymphatic glands 
give evidence of suppuration, take the patient oft his feet, 
apply compresses, tr. iodine, ichthyol, and, if necessary, 
inject into the gland fifteen drops of pure carbolic acid. 

Abscesses of the Urethral Follicles. 

It has been shown that the surface of the urethra is lib- 
erally studded with openings of larger or smaller propor- 



ABSCESSES OF THE URETHRAI. FOLLICLES. HI 

tions, in the anterior and in the prostatic portions these 
crypts are especially abundant. During an attack of 
gonorrhoea it happens that septic matter finds its way into 
these orifices and complicates the situation by the develop- 
ment of abscesses. When the smaller mucous follicles 
become the seat of such disease it may pass unnoticed, the 
only feature may be a slight induration, and the pus may 
form, and escape through the urethra, giving rise to slight 
pain and tenderness. The urethral orifice of these glands 
may become closed and the pointing of the abscess may be 
upon the outside ; it is then the infectious element invades 
the peri-glandular tissue and may give rise to extensive 
destruction of the parts, leaving behind unsightly de- 
formity. Under such circumstances this communication 
of the urethra with the deeper structures may lead to ex- 
travassation of urine and a slough result, or it might leave 
behind a fistulous tract, or stricture. The importance of 
such a complication will be measured by the size, situation 
and extent of abscess formation. It matters little which 
opening or gland is involved, the pathology is the same 
and the treatment should be directed to meet individual 
conditions. 

Should the lacuna magna participate in such inflamma- 
tion little difficulty is offered 5 being within easy reach, the 
part may be incised and applications can be made that 
will promptly restore it. The deeper parts may be cared 
for by making an application of pure carbolic acid, through 
a speculum or endoscope, or with a deep urethral syringe ; 
should such inflammation develop, and pronounced in- 
flammation and induration with evidence of suppuration 
arise, the area may be cocainized and the tumor freely 
opened, curetted, packed and the part permitted to heal ; in 
fact this is the treatment for this condition ; by so doing you 
many times will obviate reinfection of the urethra, and 



112 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

the subsequent development of fistula. Should Cowpers 
glands become inflamed the condition is called Cowperitis. 
Here, as with other glands, the one involved may or may 
not go on to suppuration, the symptoms will be propor- 
tionate. Should the gland attain an undue size, become 
painful, pus is surely present, and the situation demands 
incision and surgical care. The importance of these two 
glands is such that calls for active and positive treatment. 
Everything should be done to prevent abscess formation 
and destruction ; rest, leeches, cold compresses, etc. , should 
be employed. 

Abcesses resulting from invasion of the peri-urethral 
structures by the gonococci, if situated near the bulb of the 
urethra, demand the closest attention. The first evidence 
of infiltration of urine calls for external urethrotom}' . 

Diseases of the prostate incident to posterior gonor- 
rhoeal infection will be considered in the chapter that fol- 
lows. 

Seminal Vesiculitis. 

Inflammation of the seminal vesicles is the result of in- 
fectious elements gaining access to these parts; here, too, 
gonorrhoea holds first rank as an etiological factor. Like 
most inflammatory diseases of the genitals, any unclean 
material finding its way into such parts, disturbs the 
nutrition to an extent that a pathologic state results; thus, 
infectious matter from contiguous regions, from instru- 
ments, medicines, congestion incident to sexual excess, 
masturbation, traumatism, constipation, etc., are given as 
causes. There can be no doubt to-day that many cases of 
this kind have been misinterpreted, for our knowledge of 
this disease has remained very incomplete prior to the 
recent work of Mr. Jordan Loyd. 

Inflammation of these organs are associated with similar 
processes of the deep urethra and epididymis; when it ap- 



SEMINAL VESICULITIS. 113 

pears as a complication of gonorrhoea it is developed late 
in the course of such disease, usually between the third 
and sixth weeks. 

Symptoms. 

Rarely are both vesicles involved. Two forms of this 
inflammation are recognized, acute and chronic. In 
the acute variety the characteristics are much more 
pronounced; pain either of a continuous or throbbing 
kind is the most constant and pronounced symp- 
tom. This is often referred to the neck of the blad- 
der, rectum or pelvic region; it is difficult to locate and 
describe. The patient will suffer from irritability of the 
bladder ; the bowels, when constipated, act with much diffi- 
culty. 

When the rectum is loaded with feces and the bladder 
full, there is undue pressure upon the part, and increased 
discomfort results. The usual reflex neuralgias are pres- 
ent, suppuration is rare; when pus is forming or present 
the above symptoms, together with chills, fever, nausea, 
headache, etc., will be present. 

The onset and development of this condition, with such 
a train of symptoms will be rather rapid in the acute type, 
while in the chronic there may be some of the above feat- 
ures wanting, or all may exist in a milder and modified 

way. 

Diagnosis. 

Posterior urethritis, cystitis and prostatic diseases offer 
many symptoms in common mth disease of this part, dif- 
ferentiation is often impossible. Through the rectum 
alone can these organs be reached and then only when 
everything is favorable. Should the prostate be appre- 
ciably enlarged in its antero-posterior direction it is ex- 
ceedingly difficult to palpate the vesicles. The bladder 
should be well filled with some appropriate solution, the 



114 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

patient placed in the lithotomy position, the index finger 
anointed and the vesicles outlined ; pressure upon the dis- 
tended bladder will greatly facilitate the examination. If 
diseased, the vesicles will be found full, doughy and painful 
upon pressure. Stripping may result in their contents 
being expelled into the urethra, and the first portion of 
water voided may show the nature of their contents, which 
may be blood or pus. 

Prognosis. 

Occlusion of the ejaculatory ducts may follow inflam- 
mation of these organs, or some part of the loops may be- 
come closed, therefore it is hardly justifiable to treat the 
matter lightly. Again, I know of no condition more un- 
certain and rebellious to treatment. I believe most cases 
recover; all do not, I am sure. . . 

Treatment. 

There is little in the treatment, as we know it, that is 
direct. Removal of the cause, if such be possible, is in- 
dicated. Sexual and urethral hygiene is important. 
Pain should be controlled by the usual remedies; the 
bowels looked to. Hot water injections act kindly. Much. 
stress is attached by Dr. Fuller to milking the vesicles, 
and I am quite positive that massage, when it can be ap- 
plied properly, is most serviceable. I am not inclined to 
consider it as easy of application, however, as it appears. 
Much practice is essential to its correct performance. 

Here, as elsewhere in this region, the mental and nerv- 
ous systems are often much influenced. I have several 
times been alarmed at the depressed state of spirits that 
has developed on this account. Much tact, patience and 
skill are often required to meet the wishes of such a pa- 
tient. I have used galvanism upon the parts with satis- 
faction ; the cold douche is grateful. Should pus form the 



EPIDIDYMITIS. 115 

tumor can be aspirated through the rectum ; counter irri- 
tations to the perineum, leeches, etc., may be beneficial. 
The following prescriptions internally may be tried. 
Exs. 40 and 41: 

No. 40. No. 41. 

R. — Sodii salicyl 3iii- R- — Camph. mono. brom..gr. xl. 

Liq.' potass arsen 5iss. Ex. hyoeyam pulv | 

Peps. cord. P. D. & Co..Siii. Ex. eann. ind.. Ua. gr. iv. 



Ex. cascara aromat. fld..§i. 



pulv.. 



^ f^ g^j^ Ex. cascara sag. gr. xx. 

o* A ^ * £ 1 • 4. M. ft. caps No. XX. 

S. — A teaspoonful m water ^ 

J, , S. — One four times daily, 

every four hours. •' 

Epididymitis. 

Epididymitis, or swelled testicle, is an inflammation of 
the epididymis. It is one of the frequent and painful 
complications of gonorrhoea. It usually announces itself 
during the third or fourth week of the disease and com- 
plicates about five to ten per cent, of such cases. Other 
micro-organisms may become responsible for such inflam- 
mation, and traumatism can produce it. Stricture of the 
urethra and all conditions favoring deep urethral and 
bladder trouble predispose to it. The same is true of 
irritating and caustic injections, and unclean urethral in- 
struments. The weak, debilitated, and those given to 
excesses do not seem to develop this complication more 
readily than the robust and temperate. Quite ninety-five 
per cent, of the author's cases of epididymitis have de- 
veloped it as a complication of gonorrhoea. 

The left epididymis is attacked more frequently than 
the right, rarely are both involved. There is more or less 
inflammation of the tunica vaginalis, which latter gives 
rise to over-secretion and under-absorption of its serous 
exudate; hence hydrocele, more or less pronounced, is en- 
countered in the majority of such instances. The infec- 
tious materials may pass beyond the epididymis and the 



116 



GEXITO-URINARY SURGERY AND VENEREAI. DISEASES. 



testicle proper become inflamed, constituting- orchitis. 
This complication, however, is relatively rare. Two dis- 
tinct types of the disease are noted, acute and chronic, 
each determined by the character of the infecting ele- 
ment, the condition of the patient generally, and the 
resisting powers or integrity of the part itself. 

Fig. 41. 




Lyrapliang'itis and Epididymitis complicating Gonorrhoea. 

The proper conduct of the patient, and the timely use 
of appropriate treatment does much toward preventing 
this complication, and modifying its severity when in exist- 
ence. 

It is advanced by some that reflex irritation can be re- 
sponsible for epididymitis, also that the infecting element 
is transported byway of the lymphatics to the epididymis. 



EPIDIDYMITIS. 117 

It is believed also that the element may proceed through 
the genital tract to the epididymis, and there light up in- 
flammation, and yet no discoverable disease will be found 
in the parts through which this element has passed. I 
quite agree that epididymitis is occasionally diagnosed 
when there is but little else in the case except an ordinary 
gonorrhoea ; the more painstaking one becomes in his ex- 
aminations the oftener disease of the deep urethra, semi- 
nal vesicles, vas deferens and ducts will be found, and 
while the time is not at hand to deny the possibility of 
infection through the lymphatic circulation, yet the most 
rational explanation of the access of these matters to this 
part is inflammation through contiguity of tissue. 

Symptoms. 

A patient with epididymitis Avill complain of having an 
attack of gonorrhoea that is disposed to linger. It may 
or may not have been severe, perhaps one of the relapsing 
kind. • The discharge may have disappeared, except the 
morning drop, a slight febrile state is noticed, malaise, 
headache, loss of appetite, etc. There will be neuralgic 
disturbances in the back, inguinal region, and spermatic 
cord. The weight of the testicle drags heavily upon the 
cord. In the greater number of such cases the deep 
urethra is diseased and will add to the above prodromal 
symptoms (heaviness in the rectum, irritability of the 
bladder), etc. From one to four days of such disturbance 
and signs of positive inflammation in the epididymis is no- 
ticed ; the globus minor is first attacked. There will be 
pain, heat and swelling, which condition is very soon no- 
ticed throughout this entire organ, which will rapidly 
increase to several times its normal size and present its 
characteristic crescent shape, occupying the posterior as- 
pect of the testicle. Within four or five days the disease 



118 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

attains its zenith, when all subjective symptoms are most 
marked. For a day or two there is little change^ after 
which resolution begins. The symptoms gradually fade 
in favorable cases, and recovery is practically complete 
in ten days. When the tunica vaginalis participates and 
there is distinct accumulation of fluid within its two sur- 
faces, the scrotum becomes so enlarged and tense, that it 
is difficult or impossible to outline the epididymis or the 
testicle. The tumor then seems one solid mass (except 
diligence in the examination be observed). Fluctuation 
can usually be made out. This additional increase in 
size (on account of the acute hydrocle) adds both to the 
severity of the symptoms and duration of the attack. 

Epididymo=Orchitis. 

Should the infectious material pass beyond the epidi- 
dymis and in any manner invade the testicle proper, a 
like inflammatory process of this organ will result, and an- 
other, and more serious complication arises. 

The inflammation of these two parts is called epidi- 
dymo-orchitis. The tunica albuginea, or investing mem- 
brane of the testicle, is quite inelastic, and as the organ 
begins its congestive stage, and this increase of pressure 
advances, there is corresponding pain, which at times, is 
so severe that heroic measures are necessary for relief. 
The pain in this region is especially unbearable ; there 
is, in addition to the pain, a peculiar sickening ache that 
is nowhere else found. Such a complication as there 
would now be predisposes to disturbances in the scrotum, 
the connective tissue becomes infiltrated and thick, drop- 
ical and red (Fig. 41). Fever may run high, there maybe 
chills, nausea and vomiting, a dry tongue, restlessness and 
occasional delirium. The spermatic cord is, in turn, in- 
flamed, tender and enlarged throughout its entire distance. 



EPIDIDYMO-ORCHITIS. 119 

Such is a description of an average attack of epididymitis 
and adjacent inflammation, from which it will be learned 
that this disease may be so mild as not to give vise to much 
suffering or inconvenience, or it may be so severe and so 
complicated as to constitute a severe and serious con- 
dition. 

The chronic form of epididymitis is the result of 
chronic conditions, or is that low form of disease following 
an acute attack. Unclean matter associated with urethral 
stricture, chronic non-specific lesions of the urethra, and 
low vitality from various causes are responsible for this 
chi'onic form of inflammation of the epididymis. 

The symptoms in such cases are less pronounced, the 
progress less rapid, both as regards its onset and its de- 
cline. AVhen the epididymis takes on inflammation due 
to the existence of gonorrhoea, it is usual to note a cessa- 
tion of urethral discharge, and when the inflammation in 
the epididymis abates the discharge reappears. 

Prognosis. 

While an ordinary attack of epididymitis runs its 
course (mild or severe), as the case maybe, and the parts 
appear in their usual health, it would seem that the favor- 
able prognosis, that is so universally agreed upon, is 
proper, yet I am convinced that this disease is of much 
greater moment than many believe. There is almost in- 
variably a high grade inflammation of that long, con- 
voluted tube that constitutes the epididymis, and the vas 
deferens, and often the hard irregular places left after an 
attack of epididymitis are occlusions of the canal ; there- 
fore I am forced to believe that sterility is often due to 
such inflammation. 

It is a wise and fortunate provision of nature that there 
are two testes, and fortunate, too, that both are involved 
so rarely. 



120 GENITO-URIXARY SURGERY AND VENEREAI. DISEASES. 

Diagnosis. 

The etiology of epididymitis is so constant, the symp- 
toms so prononnced, the location and appearance of this 
body when inflamed so characteristic that there is little 
room for an error in diagnosis. In those very rare instances, 
where a testicle has continued undescended, being retained 
within the abdominal ca^dtyor inguinal canal, an epididy- 
mitis might be obscure; obstruction to the intestines, 
localized peritonitis, etc., might be suspected. A careful 
examination of the genito-urinary tract will clear the situ- 
ation of doubt. 

Treatment. 

Seldom, if ever, is epididymitis a disease per se, but 
almost invariably appears as a complication of urethral 
disease, the infecting element spreading to new areas and 
awakening the parts in turn to a state of disease, hence 
our best efforts should be in the direction of prophylaxis. 

Since the complication is so painful and serious, never 
should an opportunity be lost to limit urethral disease and 
confine it to safe and accessible parts of the canal. What 
has been said in reference to the treatment of gonorrhoea 
and urethral inflammation has a place in the preventive 
treatment of epididymitis. Since the bicycle has become 
so universally adopted as an instrument of pleasure, recre- 
ation, and business, its use should be forbidden in the 
most positive terms during urethral disease. 

It is in this connection that the surgeon, on account of 
the nature of the disease, is forced to prescribe for the 
patient, when positivelyassured that his measures will not 
be executed. Seldom will a patient be taken off his feet 
so long as he can manage to walk, and even then he will 
decline to take his bed and receive proper attention. 

The first moment he is aware that his trouble is better 
he is up and going, so it is that the surgeon is denied the 



EPIDIDYMO-ORCHITIS. 121 

value of those things most useful in the management of 
epididymitis. Whether the patient disregards the instruc- 
tions given him, on account of his surroundings or his 
pleasure, it is, nevertheless, our duty to advise him fully 
upon all matters of treatment. 

Should the subject of gonorrhoea have a redundant 
scrotum, a varicocle, or give a history of having a previous 
attack of epididymitis, a tight-fitting suspensory bandage 
is a necessity ; the use of such will do much to preserve the 
integrity of the part. 

Where inflammation of this part is at hand, the indi- 
cations for treatment are those calculated to subdue the 
disturbance and promote early resolution. Eest in the 
recumbent posture should be the first demand. Elevation 
and support of the scrotum, the bowels should be freely 
opened, a light diet ordered and all urethral medication 
stopped. The comfort of the patient should next be con- 
sidered ; hot applications in the form of fomentations or 
poultices do much to relieve the pain and limit engorge- 
ment. The fomentations may be made by arranging sev- 
eral layers of lint, gauze or flannel, of a size that will gen- 
erously cover the scrotum ; this material is soaked in hot 
water, or a pint of hot water in which a tablespoonful of 
tincture of opium, tincture of lobelia, boracic acid, tincture 
of arnica, witch-hazel extract, or half an ounce of tobacco 
has been added, the cloth slightly compressed and ap- 
plied as hot as can be tolerated. The parts should be 
held well upon the abdomen with a T bandage, handker- 
chief, sling, or some suitable support, and the whole cov- 
ered with oiled silk. A second dressing should be in readi- 
ness when the first becomes cold, the second applied 
without disturbing the inflamed parts. The applications 
will require changing about every two hours. A hot 
water bag between the thighs will do much toward keep- 



121 



GENITO-URINARY SURGERY AND VENEREAI, DISEASES. 



ing up the heat. When it is impracticable to receive this 
attention, the flax seed, or powdered ehn poultices can be 
used. I have had great satisfaction from a mattress of 
rubber, coiled to fit the part and connected with a reser- 
voir of water heated to about 110 degrees Fahrenheit by 
a small gas burner. The water circulates through the 
tubing and maintains any desired temperature for any 
length of time. 

The tobacco fomentation very often serves a wonderful 
purpose; it may relieve pain at once, and in other re- 
spects adds greatly to the improvement of the part; at 
times nausea, vomiting, and relaxation follow its applica- 
tion. Leeches applied to the part do good by depletion. 

I have almost abandoned the use of tincture of iodine; 
it will blister, and seldom benefit. I have used campho- 
phenique with satisfaction; it acts as a local anesthetic, 
but it, too, will occasionally blister if closely confined. 

Prescriptions Nos. 42, 43, 44 and 45 may be used as di- 
rections indicate: 



No. 42. 
R. — Tr. verat. virid. (Nor- 
wood's) 5i 

Kali.brom 5iiii 

Elix. cinchon ^iv 

M. ft. sol. 

S. A teaspoonful in water 
every three hours. 

No. 44. 

R. — Pulv. opii gr. xx 

Ext. belladonna pulv....gr. iv 

Oleum theobromatis '^vi 

M. ft. suppos. No. xii. 
S. Insert one into the rec- 
tum every four to six hours 
to relieve pain. 



No. 43. 

R. — Quininas sulph 5^ 

Phenacetinum 5ss 

M. ft. caps. No. xii. 
S. One every two or three 
hours to relieve pain and sub- 
due fever. 

No. 45. 

R. — Sodii salieylas '^iv 

Morph. sulphas gr iv 

Aqua menth. pip '^iv 

M. ft. sol. 

S. A teaspoonful in water 
every two, three or four hours 
to relieve pain and promote 
rest. 



Any remedy whose action tends to lower arterial ten- 
sion is beneficial. In those cases where the production of 



EPIDIDYMO-ORCHITIS. J 23 

fluid aggravates the situation, a trochar may be intro- 
duced and the fluid withdrawn. At all events the patient^ 
must be made comfortable. Should the above recom- 
mendations fail, morphia should be given in quarter-grain 
doses (hypodermatically) every three hours until relieved. 

Strapping the testicle is an old practice and one that 
never fails to benefit, if properly performed. It is useless 
to say that unequal pressure will intensify the pain and 
add to the disease. The testicle should not be strapped 
when in a state of inflammation so acute as to develop 
extreme pain when handled. Absolute rest is here called 
for. 

If the tumor can be manipulated with comparative 
comfort, strapping is indicated. Eubber adhesive strips, 
about half an inch wide and eight inches long, should be 
prepared, and arranged in easy reach of the operator, the 
plaster should be warmed and handled by an assistant, 
the parts should be shaved and sponged with alcohol. . 

The -patient should be semi-recumbent, the testicle 
should be gently pressed to the bottom of the scrotum, 
the thumb and finger of the left hand then encircles the 
scrotum above the testicle, making a neck or constriction 
so small that the testicle can not pass through ; this pres- 
sure is increased until the neck or constriction will only 
admit a body the size of a normal organ ; it is at this point 
that the first and* most important step is taken; it is here 
that, the first strip is placed, so encircling the scrotum 
that its presence takes the place of the fore-finger and 
thumb, which are removed as the plaster is applied; over- 
lapping and below this strip a second is placed, and so on 
uniformly until such strips will no longer take smooth 
and even place. The uncovered scrotal tissue at the bot- 
tom will look congested and tense. This portion is cov- 
ered and compressed with strips applied at right angles 



124 



GENITO-URINARY SURGERY AND VENEREAL DISEASES. 



to the circular in such a manner that the operation ^ when 
complete, has the appearance of a basket woven snugly 
about the part. There will be some pain at first; pains 
may run up the cord into the abdomen, but when the 
work has been properly done, and time allowed for the 
organ to rest, there will be great relief and comfort. 
Such a dressing as this should be removed when it ceases 
to accomplish the object. If the discomfort and suffering 
is avigmented after two or three hours, it is evident that 

Fig. 42. 




White's scrotal compressor. 

the organ was not in proper form for strapping, or that 
the work was not well done; in either instance, warm 
alcohol should be applied, the dressing removed, the 
organ rested, and re-strapped. When the swelling has 
subsided to an extent that the pressure from the strapping 
is no longer maintained, the first dressing should be re- 
moved and replaced by a second, and so renewed from 
time to time until there is no longer pain or swelling. 

Often a strapped testicle suspended in a well-fitting 
suspensory will enable a sufferer to go about his business 
with comparative ease. 



ORCHITIS. " 125 

I have seen no device equal to it, and in all those cases, 
where the patient will not, or cannot be taken off his feet, 
there is nothing that so effectually takes the place. 

In the shops are found many supports that are service- 
able and convenient; they are better than strapping 
poorly done, but inferior to good work. Fig. 42 repre- 
sents an excellent pattern. 

The actual cautery applied to several points of the in- 
flamed epididymis is recommended, also the application 
of counter irritants. I have used the cautery a few times ; 
it certainly is not a popular thing to engage, nor am I 
convinced that the end justifies the means. Whatever 
be the treatment proposed for trouble here, that which 
brings the greatest comfort and relief, as a rule, is the 
most efficacious; the treatment that has done this and 
favorably influenced the inflammation is to be continued 
until there is entire restoration of the part. 

Thickened, hard, and even painful areas may be left in 
the epididymis, or in the vas deferens ; these should be 
cared for. The part should be supported with a suspen- 
sory, mercurial or lead ointment, applied and the general 
health promoted. 

Orchitis. 

Inflammation of the secreting structures of the testicle 
is called orchitis. This disease, as compared with epidi- 
dymitis, is quite rare. Gronorrhoea and urethral disease 
predispose to it, while the metastatic condition, so i3oorly 
understood, appearing during an attack of mumps, con- 
tributes the greatest number. About five per cent of all 
attacks of mumps in young men (about the age of pu- 
berty) offers such complication. Just what the connection 
between the parotid gland and the testicle is, observers 
and students are not agreed, and a work of this kind 
would hardly be the place to discuss such matters. One 



126 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

testicle only is attacked; as a rule, the right somewhat 
oftener than the left. Typhoid fever, malarial fever, ton- 
silitis, traumatism, or syphilis, may be the cause; often 
no rational explanation will be offered for its develop- 
ment. A perceptible percentage of the author's cases 
have given only a history of a strain, due to heavy lifting. 
Sexual excess, exposure to cold, and the rheumatic dia- 
thesis are also given as causes. 

Prognosis. 

A prognosis must be guarded, for it is very seldom that 
the organ in true orchitis is ever the same as before, and 
often the condition results in a complete sacrifice of it. 
I have seen the disease appear as a complication of mala- 
rial fever, and in the face of every attention, suppuration 
take place and the entire secreting portion of the organ 
come away as necrotic shreds. Orchitis complicating 
mumps is not so destructive, though here every attention 
should be devoted. 

Symptoms. 

As nutritive disturbances in the testicle multiply, and 
congestion begins, the organ begins to increase in size, 
with little change in shape. Its investing membrane (the 
tunica albuginea), being inelastic, is soon put upon the 
stretch and. pain is evoked as this progresses. The tone 
and degree of this pain very often is marked beyond all 
proportion to the swelling. This symptom being so pro- 
nounced, that rest is impossible, nausea, vomiting, dull 
headache and fever come on. The testicle is drawn 
toward the abdomen on account of spasm of the cremaster 
muscle and dartos ; the slightest motion is complained of, 
and no position, application, or support, will bring com- 
fort. Such a state will continue for several days ; pres- 
sure necrosis may develop, which will promptly end the 



ORCHITIS. 



pain, and the usefulness of the testicle at the same time; 
or pus may form, fluctuation may be detected, and a lib- 
erating incision may relieve the symptoms and enable the 
part to recover completely or partially. 

In some cases there is a mild decline of symptoms fol- 
lowed by gradual improvement, the testicle all the while 
undergoing a process of induration, until the organ ap- 
pears reduced in size and altered in shape and function. 

There may be a stony hardness of the testicle and the 
entire side of the scrotum much reddened. Very often 
the formation of pus takes place in several parts of the 
testicle, and as many fluctuating areas are noticed, when 
opened these points discharge pus for a time; later the 
openings become plugged with a necrotic fibrous material 
that is diflicult to remove. This pushed back, a flow of 
pus follows, this fibrous element is the necrosed tunica 
albuginea, often the testicular substance presents; after 
a time this material becomes detached, and long extensive 
masses . are removed with forceps. Such a condition 
means, that the inflammation and pressure, has been so 
great that death of the part has resulted. At these little 
openings a red vascular little mass may appear, which 
may increase in size until it assumes conspicuous propor- 
tions, from the side of which a small fistula will be no- 
ticed leading down to the remaining portion of the testicle ; 
through this little opening a few drops of pus may pass 
daily; this state may persist for many months. Through 
such a surface infectious material may find access and be- 
comes responsible for new abscesses. 

Treatment. 

When a diagnosis of orchitis is reached, the recumbent 
posture with hips elevated should be demanded, the 
bowels freely opened, the diet kept low and unstimulating, 



128 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

the testicle should be freely depleted with leeches^ and 
kept at perfect rest. So long as this treatment prevents 
engorgement it should be continued. Should the pain 
increase it is evidence that the measures are inefficient 
and demand that the tension must be further lowered, 
which may be accomplished by local blood-letting and ice 
to the part. Should this fail, the tenotome should be 
made to cut the tunica albuginea in from six to twelve 
places until relief to the part is had. (A few drops of 
cocaine inserted under the skin renders this operation 
painless.) After this operation the part may be treated 
with a lead and opium lotion, hot or cold applications, 
poultices of tobacco, lobelia, witch-hazel, etc. Opium, 
hypodermatically, by the stomach, or suppository, should 
be prescribed when indicated. Should pus form, free and 
early opening with surgical care is necessary. Exuberant 
granulations or fungoid growths found about the open- 
ings may be clipped off, burnt with nitric acid, or treated 
to dry dressings. Their presence associated with fistulse 
means an infection, and the best cure is to open up freely 
and remove the focus. When the necrotic tissue presents 
at the openings made for the liberation of the pus, gentle 
effort should be made to remove it, otherwise all that re- 
mains of the testicle may come away with it. The cardinal 
points of treatment are: Keep the patient and the part- 
absolutely at rest; if necessary narcotize one or both. 
Should inflammation increase, leeches or local blood-let- 
ting; should this fail don't delay the incisions into the 
tunica albuginea ; relieve the pressure before gangrene is 
induced. 

Epididynio=Orchitis. 

As indicated by the name, epididymo-orchitis is an in- 
flammation of the epididymis and testicle. All those in- 
fluences capable of exciting nutritive disturbances in 



DEFKRENTITIS. 129 

either of these organs predisposes to trouble of this kind. 
When gonorrhoea or other septic material from the deep 
urethra finds its way to the epididymitis it is only a step 
further to the testicle, and much oftener than some be- 
lieve the latter becomes invaded and diseased. When this 
condition is met all that has been offered in the way of 
diagnosis, prognosis, and treatment of the troubles inde- 
pendent of each other should be insisted upon. 

Deferentitis. 

By far the greatest number of inflammatory diseases of 
the genital tract are those due to septic infection, gonor- 
rhoea being the most prominent. That the element 
travels in any other way than by contiguity of tissue very 
few believe. For many years it was held that the infect- 
ing germ traveled by jumps, thus skipping certain por- 
tions. 

In the light of modern science, such theories fall ; there- 
fore all areas trespassed upon by these destructive agents 
are more or less damaged. When the vas-deferens has 
become the pathway for gonocci or other pyogenic micro- 
organisms there is resulting inflammation, which has been 
given the name of Deferentitis or Funiculitis. 

Rarely does this inflammation receive recognition or 
treatment, for an inflammation of the seminal vesicle, 
epididymis, or testicle, which is usual when the vas- 
deferens is infected, overshadows it. 

When inflamed the vas-deferens becomes enlarged, ir- 
regular and tender. The pain is often complained of in 
the pelvis or rectum, and often rather hard to locate. 

Cystitis. 

Inflammation of the urinary bladder is called cystitis. 
Two such diseases are known, the acute, and chronic; the 
latter, however, is distinctly different from the former, as 



130 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

will subsequently be shown. Gonorrhoea as a causative 
factor in acute cystitis is as constant as in the develop- 
ment of complications in the genital system. Unclean 
matters introduced into the bladder through improper, or 
injudicious use of instruments, bearing infectious ele- 
ments, stone fragments, over-distention due to any cause 
whatever, abnormal urine, improper urethral and bladder 
injections and irrigations, the internal use of those 
drugs containing turpentine, cantharides, etc., stricture of 
the urethra, prostatic hypertrophy, the influence of cold, 
pressure from tumors, and traumatism, may cause cystitis. 

Symptoms. 

If there is present gonorrhoeal disease in the deep 
urethra, or evidence of recent inflammation due to other 
causes, the bladder neck as it is encroached upon will be 
first to show disturbance ; there will be developed in addi- 
tion to the symptoms of posterior urethritis, a tenesmus, 
that may be so mild as to cause but little discomfort, or so 
extreme and constant as will force the patient to devote 
himself to acts of micturition every few minutes ; being 
driven by this ungovernable impulse, he will strain with- 
out relief, forcing only a few drops of urine, mixed with 
blood, pus and mucous. 

Notwithstanding the fact that gonorrhoea has been re- 
sponsible for cystitis, seldom does the bladder lining be- 
come involved, the inflammation is usually located near 
the neck; nor can pure cultures of gonococci be grown 
from inflamed bladder tissue. There will be bladder and 
hypogostric tenderness, heavy feeling in the rectum, and 
radiating neuralgic pains in the back, thighs, penis, and 
testicles. 

Mild constitutional disturbances are noted. 



CYSTITIS. 131 

Diagnosis. 

The frequent occurrence of cystitis, the pain, incon- 
venience and importance attached to it, its amenability 
to treatment, render it important that it should be dis- 
tinguished from those conditions giving expression to the 
same character of symptoms. Deep urethral disease will 
often be a part of the trouble, so may diseases of other 
neighboring parts, which are to be recognized. The urine, 
perhaps, offers the most positive guide, and very often 
through it alone a diagnosis can be made. 

Early in the disease the urine is acid, which when voided 
into a clear glass and permitted to stand a few minutes, 
the specimen will display itself in two distinct strata. 
The bottom layer will be pus; it will look thick, white 
and granular ; the upper layer will be cloudy but less dense, 
and will consist largely of mucus with some pus, and a fair 
idea of the extent of the inflammation will in this way be 
gained. If the trouble be of considerable duration or 
should some obstruction to the outflow of urine exist, and 
more or less retention result, the urine will undergo putri- 
factive, or ammoniacal decomposition; it will then be 
alkaline in reaction, bacteria, amorphous, and triple-phos- 
phates will be present, and it will have an unnatural 
(sometimes putrid) odor; it will be thick, tenacious and 
ropy; it will adhere to the side of the glass. Such a con- 
dition cannot fail to be recognized and means cystitis. 
The three-glass test is very satisfactory. Have the urine 
passed in three glasses ; if the first portion of urine con- 
tains pus, and the other two portions remain clear, you 
are safe in concluding that the debris came from the deep 
urethra and that the bladder is not involved. Should the 
first urine passed contain pus, and the second and third 
portions be turbid, the second more so than the third, you 
are to believe that the bladder neck as well as the deep 



132 GENITOURINARY SURGERY AND VENEREAL. DISEASES. 

urethra is inflamed. Should the first urine passed be 
clearer than the second, and the second clearer than the 
third, we understand that there is less inflammation in 
the deep urethra than at the bladder neck, and that there 
is inflammation within that has produced a heavy sedi- 
ment in the bladder, hence the very turbid appearance of 
the third portion. Application of the usual test for pus 
will demonstrate its presence. 

Chronic Cystitis. 

This form of inflammation of the bladder may succeed 
the acute, and continue indefinitely as a low catarrhal 
process, taking on acute symptoms at times, and lapsing 
again into a sub-acute state, or, as is most frequent, the 
trouble, may come on slowly and never become acute. 

This is especially true of that vast number of sufferers 
belonging to the class of prostatics. Little by little the 
drainage level of the bladder is raised, by the slow increase 
of the prostate, residual urine increases as this is done, 
ammonia products, and micro-organisms, excite inflamma- 
tion and there is cystitis. 

Not alone is prostatic hypertrophy responsible, but 
strictures of the urethra, tumors pressing upon the parts, 
and all those influences impeding and obstructing the 
urinary flow. 

Treatment. 

The treatment of cystitis should be direct and indirect. 
Whether it be due to gonorrhoea, obstruction or any other 
cause, the management is essentially the same. Here 
again, rest is of first importance; such a condition of 
quiet is at times necessary that on the surface of the urine 
in the bladder there is not a wave or ripple. The hips 
should be raised and the urine kept from the bladder 



CHRONIC CYSTITIS. 133 

neck. The general health should be cared for, and the 
nse of such demulcent diuretics as will flush out the blad- 
der with minimum discomfort. 

For the accomplishment of this purpose, the following 
prescriptions will be found useful : 

No. 46. No. 47. 

B:.— Ext. zea mays, fld giii ^RL.— Urotropin gr.c 

Ext. hyoseyam. fld 5i Ft. chart No. xx. 

Acidum benzoieum 3ii S. One powder in a glass 

Ext. eascara sag gi of water after each meal. 

^J- Often of great service when 

S. A teaspoonful in a the urine is alkaline and 

wineglassful of water four much decomposed, 
times a day. 

No. 49. 
'^. — Ext. triticum repens fld-.^iii 

^o. 48. . Ext. rhus aromat ) ^. 

^.. — Ammon. benzoat 5" Ext. saw palmetto.... J ^^ 

Ext. belladon. pulv gr. iii Lithii salieylas ^ ss 

M. ft. chart. No. xii. M. 

S. One powder in a cup of S. A teaspoonful in water 

hot water three times daily. after meals. 

Copaiba, cubebs, boric acid, pareira brara, potassium 
chlorate, salicylic acid, the sulphites, turpentine, etc. 

At all events it is desirable that the urine be kept 
slightly acid. No remedy should be used that will act in 
opposition to this end. Fresh fruits I have found to be 
admirable in many ways. 

Vesical tenesmus should be quieted. If necessary Rx. 44 
may be resorted to. Sulphonal in ten to twenty grain 
doses will often promote sleep, and needed rest. The 
bladder should be washed once or twice daily, using 
nitrate of silver, two to five grains; boric acid, one ounce; 
permanganate of potash, five to ten grains, or sulphate of 
zinc, twenty grains, to the quart of warm water. 

In all those situations, where cystitis develops as a result 
of obstruction to the urethra, permanent success will 
depend upon the location and removal of such obstruction. 



13-i GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

Ureteritis. 

Infectious elements from the bladder find their way to 
the kidney through the ureter and leave this narrow canal 
in an inflamed state ; small kidney stones pass down the 
ureter, doing more or less damage, and exciting inflamma- 
tion; careless abdominal surgery often damages the 
ureter; malignant and tubercular diseases attack it. It is 
probable that ureteritis exists oftener than is recognized. 
During the passage of a stone, the pain is of an agonizing 
character, and so confined to the part that an error in di- 
agnosis is not likely to occur. The other forms of in- 
flammation are much less pronounced, the symptoms less 
definite, necessitating much care and accuracy in reaching 
a diagnosis. Appropriate treatment would be the correc- 
tion of the underlying condition, together with such gen- 
eral and palliative measures as may be indicated. 

Pyelitis complicating gonorrhoea will be considered 
under Diseases of the Kidney. 
* 

Qonorrhceal Conjunctivitis. 

This active and rapidly destructive form of conjunctivitis 
encountered in adults, is synonymous with purulent, 
and blennorrhagic conjunctivitis. When met with during 
the first ten days of infantile life, it is called Ophthalmia 
Neonatorum. In either situation the disease is the result 
of infection of the conjunctival mucous membrane with 
discharges containing gonococci. These parts are pe- 
culiarly susceptible to infection from this source, the mi- 
nutest quantity of such pus conveyed in the most indirect 
manner is all that is necessary to establish the disease 
with all its fury and serious consequences, hence the ne- 
cessity of extreme precaution on the part of the surgeon 
handling such disease, and the patient possessing it. 



GONORRHCEAI. CONJUNCTIVITIS. 135 

Symptoms. 

There is an incubative period varying from one to four 
days (often the moment of infection was not noticed). 
The first symptoms complained of will be an itching, 
burning sensation, with undue lachrymation. The 
conjunctival surfaces will be injected and red; the several 
steps of inflammation will soon appear, perhaps, within a 
few hours migration of the plastic elements will develop, 
when much swelling, photophobia, and a copious discharge 
of pus will be in evidence. Such a condition steadily 
deepens for three or four days, when the attack attains its 
zenith. At this time the lids may be so oedematous, and 
inelastic, and the suffering of the patient such, that it is 
difficult or impossible to so manipulate the parts that a 
clear and complete inspection can be had. The inability 
to free the eye of pus, and the pressure on the cornea adds 
additional danger to the situation. Added to the swell- 
ing of the palpebral, is a like state of the ocular con- 
junctiva; as the lids are opened a mass of puffed, rough- 
ened and reddened tissue is noticed, at the center of 
which the cornea can be detected. Associated with this 
local condition are mild constitutional disturbances, some 
headache, fever, and general discomfort; on account of 
pain, loss of sleep, etc., the digestive and nervous sys- 
tems may suffer. 

Diagnosis. 

All violent inflammation of the conjunctiva in an adult 
suffering, or in those who have recently suffered an attack 
of gonorrhoea, or with those whose work brings them in 
contact with such infectious matters, namely, doctors, 
nurses, chambermaids, etc., or purulent eye disease in the 
newborn, is to be regarded with suspicion. If gonococci 
can be found from a microscopic examination, the diag- 



136 GENITO-URINARY SURGERY AND VENEREAI. DISEASES. 

nosis is assured. The behavior of this disease bears such a 
contrast to the other forms of conjunctivitis that little 
difficulty is offered in differentiation. 

Treatment. 

From the brief description of this disease, it is evident 
that the treatment should be vigorous and complete. It 
is my custom to refer such cases to the Ophthalmologist. 
It is not always convenient or possible to do so however^ 
hence the necessity of a proper conception of those meas- 
ures so essential here. The course pursued by this dis- 
ease is so rapid that no time should be lost. 

A bed, a darkened room, a nurse, and a generous supply 
of surgical dressings should be had at once. The second 
eye should be protected with a watch crystal, fitted to a 
collodion dressing. It should be so shut off that no ma- 
terial from the diseased eye can reach it. Free purgation, 
leeches, iced compresses every fifteen to twenty minutes, 
preceded by free irrigation with a boric acid solution, or 
1-10000 bichloride of mercury solution. The general com- 
fort of the patient should be looked after, and an appro- 
priate anodyne employed, if indicated. Should the cornea 
become ulcerated and give evidence of perforation, the 
pupil should be dilated with a solution of atropine (two 
grains to the ounce of water) if the ulcer be central; the 
pupil should be contracted with a solution of eserine (one 
or two grains to the ounce of water) if the ulcer be pe- 
ripheral. Under such conditions, the remedy indicated 
should be used at such intervals as will keep the pupil di- 
lated or contracted, as desired, until all danger of perfora- 
tion and prolapse of the iris is passed. 

Nitrate of silver (five to ten grains to the ounce of 
water) is often of great value. It can be used by drop- 
ping into the eye, or, what is better, evert the lids and 



GONORRHCEAI^ RHEUMATISM. 137 

apply the solution with tooth-pick and cotton. Such an 
application should not be repeated until the parts have 
recovered from the previous application. No dress- 
ing that is heavy should be used, and no dressings should 
be used a second time. As the disease declines the treat- 
ment may be modified. 

Qonorrhoeal Rheumatism. 

This disease is one about which there is much diversity 
of opinion. Many theories have been offered in explana- 
tion. That there is such a condition as gonorroehal rheu- 
matism, and that certain individuals suffering from an 
attack of gonorrhoea almost invariably develop a rheu- 
matism which comes and goes with the disease, there 
is no doubt. It has recently been shown that joints 
attacked have contained gonococci, and their presence 
in the blood has been established by no less a patholo- 
gist than Dr. W. H. Welch. Personally, I have 
verified the correctness of the first statement, by find- 
ing these micro-organisms in the serous exudate of 
the knee joint, though I have never demonstrated their 
existence in the blood. Guided by the work of 
Hewes, Welch, Finger and others, it would seem that 
nothing is wanted in this direction. 

This disease is always dependent upon gonorrhoea ; 
the other forms of urethral inflammation have never 
been known to develop it. It may involve a single, 
or any number of joints, the synovial sheaths, bursse, 
eye, or muscles, may be the seat of such disease. 
Usually it develops late, between the third and sixth 
week, of an attack of gonorrhoea, though it has been 
encountered as early as the sixth day. Something like 
two per cent of gonorrhoea! subjects suffer from this 
form of rheumatism, which may be acute, sub-acute, 



138 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

or chronic. There ma}^ be found about the jo hit, as a 
result of this inflammation, pus, sero-pus, a sero-fibri- 
nous, or a serous exudate, dependent in each instance, 
upon the character of the morbific element exciting the 
attack. The gonococci, either alone or through their 
toxines, are believed to be responsible for this rheuma- 
tism, where the effusion is serous or sero-fibrinous ; 
while other pyogenic micro-organisms are believed to 
occasion the purulent and sero-purulent varieties. The 
table, so carefully formulated by Finger, is interesting. 
It affords, at a glance, a very correct idea of the sus- 
ceptibility of certain joints. Three hundred and 
seventy-five cases, collected from old and new litera- 
ture, forms the basis of his work. Of these 375 cases 



The knee joint was attacked one hundred and thirty-six times. 

The tibio-tarsal was attacked fifty-nine times. 

The wrist was attacked forty -three times. 

The finger was attacked thirty -five times. 

The elbow was attacked twenty -five times. 

The shoulder was attacked twenty-four times. 

The hip was attacked eighteen times. 

The maxillary was attacked fourteen times. 

The meta-tarsal was attacked seven times. 

The sarco- iliac synchondrosis was attacked four times. 

The sterno- clavicular joint was attacked four times. 

The chondro- costal was attacked two times. 

The Intervertebral joint was attacked two times. 

The peroneo -tibial joint was attacked one time. 

The crieo- arytenoid was attacked one time. 



At least sixty per cent of the writer's cases de- 
veloped this rheumatism when there was posterior 
gonorrhoea ; in fifty per cent the disease was confined 
to a single joint; forty per cent the knee alone was 
implicated ; seventy-two per cent the exudate was 
serous ; sixty-nine per cent there was no history and 
no evidence of a rheumatic diathesis ; thirty-nine per 



GONORRHCEAL RHEUMATISM. 139 

cent had suffered previously from gonorrhoeal rheuma- 
tism, and in eighty-two per cent there was no diminu- 
tion of the urethral discharge with the onset of rheu- 
matic symptoms. 

Symptoms. 

To present the picture of gonorrhoeal rheumatism, I 
have selected an average case from my record book 
which will, no doubt, serve the purpose : 

May -30, 1897. A. S. H., age thirty-one. Family 
history and general appearance good : habits irregular ; 
had measles when about eleven years of age, mumps 
when eighteen, pneumonia at twenty-six. ]N^o syphilis. 
Had gonorrhoea at the age of twenty-six ; attack lasted 
about three months. Had stiffness and swelling of 
right knee, beginning the third week of the gonor- 
rhoea and lasting for about two or three weeks after 
the urethral discharge disappeared. Was confined to 
the bed about a week, to the house about three weeks. 
The knee was never lanced, nor did it break. 

Present condition. — May 18, 20, 23 and 26 was ex- 
posed to venereal disease. May 28, detected first symp- 
toms of urethral disease. Clinical evidence and mi- 
croscopic examination made the diagnosis gonorrhoea. 
The appropriate treatment was prescribed and especial 
care enjoined that rheumatism be circumvented. J^Tot- 
Avithstanding his previous experience and the advice 
given, he continued club attendance, moderate dissipa- 
tion and received irregular treatment. He reported in 
person June 18, complaining of stiffness and discom- 
fort in his right knee ; his urethral inflammation was 
general and active. He was ordered home, provided 
with a nurse, and the treatment of his gonorrhoea be- 
came thorough. He was visited June 19, the joint 
well padded with absorbent wool and fixed with plas- 



140 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

ter, in which was iiichided several coils of rubber 
tubing attached to a reservoir, kept hot with an 
alcohol lamp, the object being a convenient and 
constant application of heat. The bowels were opened 
with rochelle salts, ten-grain doses of salol adminis- 
tered three times daily, and sexual and urethral hygi- 
ene enforced. June 19, patient more comfortable, fever 
102^ F., pulse 109, tongue shghtly coated, bowels open, 
forty -nine ounces of urine voided in last twenty-four 
hours, slept seven hours, urethral discharge dimin- 
ished. June 20, 21. and 22 very much the same, with 
no change in treatment. June 28, cast removed ; the 
joint red, swollen and tender, fluctuation distinct ; rub- 
ber bandages applied above and below the joint (forc- 
ing the exudate to the center) , a puncture with a sharp 
bistoury and the escape of eleven ounces of serous 
fluid. A wet dressing of bi-chloride gauze, and over 
this a snug flannel bandage. The heat continued, 
the urine slightly acid, temperature 99*^ F., gen- 
eral condition improved; during the next three days 
condition and treatment essentially the same. June 28, 
temperature normal, pulse eighty, urethral discharge 
slight, joint free from pain and redness, but slightly 
swollen ; general condition good. From this date 
the improvement was gradual and uninterrupted. 
July 4: the urethral disease had disappeared, the rheu- 
matism no longer existed, and the patient w^as per- 
mitted to participate in patriotic celebrations, divested 
of alcohol and hilarity. 

Prognosis. 

As a rule, this complication of gonorrhoea recovers ; 
in the intemperate, the infirm, and those cases where 
there is large accumulation of pus in a joint the future 



GONORRHCEAL RHEUMATISM. 141 

is doubtful. It is well, therefore, to bear in mind these 
possibilities when predicting the outcome of gonor- 
rhoea! rheumatism. 

Treatment. 

From this it will be seen that there is no special 
therapy in this direction. One is tempted to prescribe 
oil of wintergreen, iodide of potash, colchicum, lith- 
ium, and the drugs useful in rheumatism. They 
may all be tried, and benefit will come only when urethral 
inflammation is improved. The time-honored balsam 
copaiba, oil of sandal-w^ood and cubebs will do more 
than the anti-rheumatic remedies. Therefore, all those 
measures having a favorable influence upon the original 
gonorrhoea, are especially recommended in this disease. 
Counter-irritants to the inflamed areas, the early and 
free evacuation of fluid or purulent collections, and 
the subsequent surgical care of such condition is nec- 
•essary, 



CHAPTEK VI. 

DISEASES OF THE PROSTATE— GENERAL CONSIDERATION— FOL- 
LICULAR PROSTATITIS— PARENCHYMATOUS PROSTATITIS 
—TUBERCULOSIS OF THE PROSTATE— MALIGNANT 
DISEASE OF PROSTATE— PROSTATIC STONES 
—ATROPHY OF THE PROSTATE— HY- 
PERTROPHY OF PROSTATE. 

Diseases of the prostate can develop as a complica- 
tion of posterior gonorrhoeal inflammation ; in fact, 
gonorrha?a is a most potent factor in devoloping 
trouble along its line of progress, as has been 
shown in the previous chapter, yet there are many 
causes for inflammation in this organ. Should gono- 
cocci or other pus producing micro-organisms that oc- 
cupy the urethra, find their way into the follicles of the 
prostate, or should debris from the bladder, unhealthy 
urine, septic material from catheters, and urethral in- 
struments, calculous particles, rancid suppositories, 
improper irrigations and instillations, or any unwelcome 
material, unwholesome manipulation, exposure or in- 
jury capable of disturbing the circulation and exciting 
inflammation, the resulting disease will be either a 
parenchymatous prostatitis (if the real substance of 
the prostate is involved) , or a follicular prostatitis (if 
only the follicles be attacked) . 

Follicular Prostatitis. 

In a general consideration of the disease of the pros- 
tate, it will be remembered that the organ participates 
in, and undergoes physiologic congestion during vene- 



FOLLICULAR PROSTATITIS. 143 

real excitation, hence ungratified sexual wishes, and such 
prolonged engorgement is often the starting point of 
disease. Improperly constructed bicycle saddles are 
responsible for injury; masturbation, constipation, 
sexual excess, stricture of the urethra and possibly 
exposure to cold. 

The most frequent pathologic condition of the prostate 
brought to the notice of the surgeon is that obstinate sub- 
acute variety, due to gonorrhoea or the result of sexual 
excess, ungratified sexual wishes, masturbation, etc., 
in which there is inflammation of both follicles and a 
mild engorgement of the prostate proper. Such a 
condition may offer a train of acute symptoms at first, 
especially if it be due to gonorrhoea ; as a rule, how- 
ever, follicular prostatitis is a chronic disease, and very 
often the only feature noticed is the almost constant 
discharge of a muco-purulent material that is mistaken 
for seminal fluid, which belief awakens apprehension, 
and becomes the foundation for much fancied trouble. 
That condition called prostatorrhoea, so prominently 
discussed and flagrantly pictured by the advertising 
specialists is this follicular disease. Such sufferers 
have devoted themselves to venery, either in thought 
or act, and their genitals very often are strangers to 
rest, hence much difficulty is added to their treatment. 

Treatment. 

Sexual hygiene holds first place. The bowels should 
be freel}' moved ; fluid extract of cascara sagrada is an 
ideal remedy. Counter irritation to the perineum has 
a double value ; a blister here will favor resolution as 
in other situations, and if the surface is freely stimu- 
lated it will afford the patient (who is usually despon- 
dent) something in the order of a change to think 



144 GENITO-URINARY SURGERY AND VENEREAL DIvSEASES. 

about. Cantharidal collodion, tincture of iodine, ich- 
thyol, guaiacol, mustard, etc., may be used. These pa- 
tients will bear with fortitude any treatment, no matter 
how painful or how heroic it may be. 

In blistering this part, it will be w^ell to remember 
that debris accumulates here, and is liable to infect 
any open surface, therefore the part should be pro- 
tected. The scrotum bears such remedies poorly, and 
should be protected or held at a safe distance. Care 
should be exercised, also, to protect the anus. Sul- 
phonal given at bedtime to promote sleep, monobro- 
mated camphor during the day to quiet the sexual 
organs, tonics to improve nutrition, cheerful and moral 
literature and those measures generally that add 
variety and pleasure to life. 

Prescriptions 'Nos. 50 and 51 will be found of much 
value : 

No. 50. No. 51. 

I^. — Fl. ext. rhamni purshi- ^. — Tr. cantharidis 5iss 

annee %i Potassii brom "^iv 

Fl. ext. cannabis indic8e..T0 Ix Elix, lactopept ^iv 

Fl. ext. liyoscyam?e Tl) 1 M. ft. sol. 

Elix. peps. bis. et strych-.^ii S. A teaspoonful in water 

M. three or four times daily. 
S. A teaspoonful in water 

after nieals. 

Iodoform applied to the prostatic urethrals of service. 
A drop of campho-phenique, a few^ drops of a weak 
solution of sulphate of copper, or nitrate of silver (two 
grains to the ounce) with a deep urethral syringe ; the 
cold sound can often be employed with advantage. 

I have used a solution of permanganate of potash 
with the apparatus represented in (Fig. 30) , by filling 
the urethra, keeping up the pressure until the muscles at 
the bulbo membranous urethra are tired out and become 



PARENCHYMATOUS PROSTATITIS. 145 

relaxed ; then fill the bladder and have the patient pass 
it out. In this way the solution acts upon the part 
both as it goes in and comes out. A soft catheter may 
be passed to the beginning of the prostatic urethra, 
the bladder filled and emptied as above. 

A follicular prostatitis may become a parenchyma- 
tous affection, and what has been said would then be 
added to what will now be presented as a description of 

Parenchymatous Prostatitis. 

When the parenchyma of the organ becomes in- 
flamed, its volume is increased and its capsule made 
tense ; on this account there is pain proportionate to 
the degree of intra-capsular pressure, which may vary 
from a slight uneasiness, to unbearable suffering. The 
exciting cause, together with the integrity of the part, 
will measure the grade and course of the attack; thus, 
should gonococci, streptococci, or staphylococci, find 
their way into the substance of the organ and the or- 
gan be poorly prepared to do battle with them, the 
trouble will be extremely acute and will pursue a rapid 
course. From its close relationship to the bladder and 
the rectum, pain and inconvenience will be complained 
of in these localities. Often the patient believes his 
trouble to be one of the rectum, and less often the 
bladder and kidneys. If the organ is perceptibly en- 
larged or tender, the index finger in the rectum will at 
once furnish very complete information. The prostate 
often becomes so enlarged that it materially en- 
croaches upon the rectum, rendering defecation pain- 
ful and producing a constant uneasiness ; the finger 
€an locate the part or parts most involved, detect fluct- 
uation when pus is present, and in a word, this consti- 
tutes the most satisfactory feature of examination. 



146 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

The swelling in the same way encroaches upon the 
urethra, and neck of the bladder, making micturition 
difficult, painful and at times impossible. 

Like the uterus of the female, the prostate bears 
disease and injury well ; inflammation in this situation 
behaves as inflammation elsewhere, the organ may un- 
dergo resolution or terminate in suppuration. There 
is a fever, which may reach 105° F. There may be 
rigors and the complete picture of pus formation. 
Prior to this time the symptoms may begin to disap- 
pear and the parts slowly return to the normal, or 
there may be a sudden giving way and a quantity of 
pus passed through the urethra, perineum, or into the 
rectum or bladder, and the symptoms disappear as by 
magic ; the patient may go on to recovery or there 
may be recurrences, followed by great depression, and 
the condition become a general septic one with doubt- 
ful future. The gland may become hard or irregular 
and on this account be responsible for inconvenience, 
or it may end in a follicular inflammation. 

The treatment is the observance of sexual and ure- 
thral hygiene. Empty the bowels with a warm injec- 
tion; if the organ is enlarged and painful, showing evi- 
dence of pus formation, I inject into the part that 
seems the center of the inflammation twenty drops of 
pure carbolic acid. This I have not seen recommended 
nor do I know of its use by another. It is my belief 
that many times I have aborted the suppuration by 
establishing premature resolution. I have made as 
many as four injections into the same gland, and 
have seen no harm come from its use ; I give 
this the first place in all those situations where 
pus formation seems the behavior. The bowels 
should be kept freely open. An appropriate anodyne 



PARENCHYMATOUS PROSTATITIS. 147 

is necessary to secure rest ; this may be a sup- 
pository in the rectum, containing one or two grains 
of opium ; morphine or codeine, one-eighth to one- 
fourth grains, either by the mouth or hypoder- 
matically. The urine should be cared for ; when reten- 
tion results, a catheter is imperative, and should be 
used with caution and gentleness. Benzoic acid, five 
to ten grains, or benzoate of soda, five to ten grains, 
three or four times daily, to prevent the formation of 
ammonia products. Rxs. 52 and 53 are valuable. 

No. 52. No. 53. * 

I^. — Lithii salicylas 5! I^.^Elix. buehu. juniper and 

S. Dissolve in a gallon of aeet. potash gvi 

water, and take a glassful S. A teaspoonful in a glass 

four to six times a day. of water, six times in twenty- 

four hours. 

The diet should be nutritious and digestible. For 
the pressing desire to urinate, which is always at hand 
when the urethra and bladder are involved, an opium 
and belladona suppository should be used in the 
rectum. 

Fever can be combatted with cold sponging; the 
internal administration of quinine suL, five to ten 
grains, every three or four hours ; acetanilid, ^ve 
grains, every three or four hours, or any antipyretic 
that is safe to use. The gland undergoing enlarge- 
ment and change in shape, does so in the direction 
offering least resistance, hence the urethra, neck of 
the bladder, and the rectum are encroached upon. 

The structures about the prostate can become in- 
flamed (peri-prostatitis) and behave very much in the 
same way as the gland proper. When pus has formed 
and its location made sure, which can be, with the his- 
tory at hand, the finger in the rectum, and by explora- 



148 GENITO-URINARY SURGERY AND VENEREAI. DISEASES. 

tion with the hypodermic needle, the tumor may be 
aspirated, or it may be incised or punctured through 
the perineum, the pus h berated and the resulting 
wound treated surgically. 

Tuberculosis of the Prostate. 

A process of caseation, beginning in the glandular 
element of the prostate in the tuberculous subject 
is a condition occasionally observed, the organ at first 
is irregular in outline, hard and not the source of much 
pain, there may be bladder and urethral trouble if this 
area is interfered with, or there may be an uneasy sen- 
sation in the rectum. There is a discharge from the 
urethra, and the ejaculatory ducts may become dis- 
eased to which additional symptoms would be added. 
Tubercle bacilli may be found in the discharge or in 
the urine. If a diligent search be made, it will 
often be that the tuberculosis of the prostate is 
found dependent upon a like condition of other parts. 
When tuberculosis is suspected here, a complete search 
for a general tuberculous condition should be made. 
The prognosis of this condition is bad, very seldom 
does improvement, even of a temporary kind, come, 
and breaking down of the prostate is to be expected. 
A slow, and tedious suppuration comes, leaving fistulous 
openings behind, which latter become infected with 
other agents, hastening the destruction, and except 
death comes on account of tuberculosis of more 
vital parts, the patient will slowly give way to exhaus- 
tion from this source. There is little treatment that 
holds out prospect of cure, it is difficult or impossible 
to dissect, or curette out the entire part. The anti- 
toxines have not afforded the satisfaction that was 
hoped, and the best that can be done to-day, is to look 



CANCER OF THE PROSTATE, PROSTATIC STONES. 149 

well to the general health of the patient, prescribe 
that diet, climate, and change that will do most for 
him, prevent complications by looking to his urinary 
organs, keep the diseased parts at rest and clean. 

Cancer of the Prostate. 

Occasionally cancer of the prostate exists, generally 
however it is secondary to malignant processes else- 
where. Such disease is more common in advanced 
than to early life, though cancer in this location has 
been diagnosed at a very early age. The symptoms 
are essentially those due to enlargement and irregu- 
larity of the organ. Malignant disease here is more 
gradual in its development than the inflammatory 
prostatic affections, and the subjective symptoms less 
pronounced. To the sense of touch, the organ is more 
irregular, not so hard, with some points that may appear 
soft ; later in the disease the lymphatic glands will show 
involvement, and cancer cachexia will appear. When 
the urethra is included, instruments may bring away 
broken down material which, examined microscopically, 
may show characteristic cancer cells. 

The treatment of cancer like the treatment of tuber- 
culosis consists in keeping up the powers of resist- 
ance, by good diet, etc., and guarding against those 
serious results following obstruction to the urethra. 

Prostatic Stones. 

Within the open ducts and follicles, of the mature 
prostate it is usual to find earthy concretions of 
varying size ; they may range from 1-1000 to 1-100 
of an inch in diameter and may not have been noticed 
at all during life. An interesting condition that de- 
veloped at a recent autopsy, was the discovery of 



150 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

eighty-two concretions of a size sufficient to be 
gathered with a scalpel and forceps (an average 
being a small bird-shot or millet seed), from the pros- 
tate of the man fifty-six years of age who had never 
known any trouble in this region. When found in the 
gland of the aged, they are very hard, usually of a 
gray color. They form, no doubt, much in the same 
way as do biliary and salivary bodies ; during their period 
of development, they take on earthy salts from the 
urine. Rarely do they require attention, often they 
eliminate themselves by a process of ulceration, which 
may be through the rectum, perineum or into the 
urethra, leaving behind a tract that may or may not 
heal. If of sufficient size to detect, and become the 
source of trouble, they may be cut down upon and re- 
moved. Undue size of these bodies shows a tendency 
to stone formation and should suggest a search of the 

bladder. 

Atrophy of the Prostate. 

Undoubtedly the prostate, under some circumstances, 
undergoes atrophic changes, defective blood supply, 
Avhether from general conditions, attended with an 
impoverished quality of blood, or from limited quanti- 
ties of normal blood, the amount being diminished by 
conditions obstructing the vessels. Little importance 
attaches to a condition of this kind . There are few symp- 
toms. Should atrophy of the glandular composition of 
the organ take place, the urethra would be denied the 
product of the gland and the spermatic fluid would not 
be complete. Should atrophy of the. muscular feature 
of the organ occur, the ejaculatory movement would 
be wanting or incomplete. Should both be involved, 
there would result a combination of the above. The 
treatment consists in the removal of such obsta- 



HYPERTROPHY OF THE PROSTATE. 151 

cles as are i*esponsible, when of a nature that will admit, 
and the employment of such tonics and alteratives as 
will best improve the general tone of the patient. 

Hypertrophy of the Prostate. 

It has been stated in a previous chapter that many 
things about the prostate are common to the uterus, 
especially is this true in this connection when the me- 
ridian of life has passed. The prostate is inclined to 
hypertrophic changes, especially the development of 
fibrous masses. Precisely what the etiology is we are 
by no means agreed. There is much that relates to 
this phase of the subject that is interesting, and much 
that is not well understood. At all events, this organ 
begins to increase in size as age advances, seldom be- 
fore the fiftieth year, usually later ; that this increase 
is participated in by both the glandular and muscular 
constituents. As this hypertrophy advances the ever- 
changing organ takes that situation most acceptable, or 
rather encroaches upon the territory of those other 
bodies offering the least resistance, hence the urethra 
and bladder is most often imposed upon (Fig. 42) . The 
enlargement is not always symmetrical, nor is the 
progress steady, though the development is usually 
slow; at times it is rather rapid, or it may progress 
for awhile, continue stationary, and begin enlarging 
again. Hypertrophy of the aged is not considered 
a disease, but rather considered a natural consequence. 

The overgrowth of the prostate very often so changes 
its original form that the organ appears to consist of 
three lobes ; this third part is usually an ovid projec- 
tion of the prostate into the neck of the bladder, where 
its presence acts as a valve during the act of micturition, 
and in this way is productive of the greatest incon- 



152 



GENITOURINARY vSURGERY AND VENEREAI. DISEASES. 



venience and damage. Again, this hypertrophy may 
be so shaped, and situated, as to constitute a bar at the 
vesical neck. Whatever be the form and location of 
this intruding mass, the symptoms, and indications for 
treatment, will be measured by the extent of disturb- 
ance, immediate and remote. 

On its own account, hypertrophy of the prostate is a 
condition of little moment, yet from its relationship 

Fig. 42. 




Hypertrophy of the prostate. 
1. Prostate. 2. Bas-fond. 



with the bladder, urethra and rectum, it very often robs 
the patient not only of many years of comfort, but 
sends many to the grave yearly who might otherwise 
have continued a useful life. 

Hypertrophy of the prostate may then be considered 
a constant menace to good health, on account of an- 
tagonism to other important organs, especially the 
urinary. 



HYPERTROPHY OF THE PROSTATE. 153 

Such a patient making application to the surgeon (on 
account of imperfect and misleading knowledge on his 
part) , Avill probably ask for something for the kidneys ; 
he will perhaps say that he has used with more or less 
satisfaction various domestic remedies, and often re- 
sorted to the usual secret nostrums that are advertised. 
When interrogated, he will admit that for some time 
the flow of urine has been slow to start, that the de- 
sire to void it is frequent, urgent, and worse at night, 
that the stream has diminished in volume and force, 
dribbling, or falling perpendicularly from the meatus, 
that the bladder continues unrelieved. He may men- 
tion that at times he has been unable to void his urine 
at all. A sensation of weight may have been noticed in 
the rectum, there are disturbances of the sexual organs 
incident to congestion, and invasion of that territory 
by the overgrowth. Neuralgic pains are complained 
of in the penis and testicles, erections and nocturnal 
emissions are usual. Disturbance of those important 
nerves found upon the floor of the prostatic urethra, 
many times gives rise to extreme and unnatural sexual 
fancies, occasionally approaching perversion, or to ob- 
literation of sexual feeling. There will be present 
in the urethra a mucus, which will be found prostatic. 
As the condition advances the urethra is not only nar- 
rowed throughout its prostatic portion on account of 
the inward pressure of the unnatural gland, but that 
part enveloj)ed by the prostate is lengthened and made 
irregular in proportion to the hypertrophy. By such 
an influence upon the urethra, and the raising of the 
neck of the bladder, the point of drainage becomes 
such that the bladder cannot empty itself. This state, 
favored by a so-called third lobe acting as a valve, or 
by the development of a bar at the neck of the blad- 



154 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

der is the beginning of trouble, increasing, and seri- 
ous. In the face of such impediment to the outflow 
of the urine, with the bladder so disturbed as to pre- 
vent complete evacuation of its contents, residual 
urine soon undergoes fermentive changes, the develop- 
ment of ammonia products inflame the organ, and the 
diseased urine exerts an unfavorable effect upon all 
parts with which it comes in contact. Urination be- 
comes more difl[icult and painful, all of the symptoms 
enumerated are heightened, the bladder walls thicken 
and lose their contractility, the viscus becomes a hot- 
bed swarming with bacteria, the ureters may become 
infected and convey disease to the kidneys, or the 
inflammation may not pass beyond the Ijladder. By 
and by, on account of sleepless nights and days with- 
out rest, weakened for want of proper apj^etite and 
low digestion, and further by a low septic state, all 
the evidence of fading vitality are upon him and the 
flicker of life is slowly extinguished, not a disease 
within itself, yet such is the course of hypertrophy of 
the prostate. 

Such a patient may die from uraemia, pyaemia, rup- 
ture of the bladder, pyelitis, pyponephrosis, or ex- 
haustion. 

How are we to diagnose this condition? How shall 
we prognose and how shall we treat it? The diagnosis 
is not difficult ; cancer and tuberculosis of the prostate, 
stricture of the urethra, and stone in the bladder are 
the diseases from which it is to be differentiated. 
Should the patient be a man fifty years of age or up- 
ward, listen attentively to his story, gather from him 
all the information that he will give you, apply to him 
such questions as will develop the true meaning of 
what he has said, and strongly suspect hypertrophy of 



HYPERTROPHY OF THE PROSTATE- 155 



the prostate if he clearly presents the symptoms pre- 
viously mentioned. Even though his narration be ever 
so convincing, a diagnosis cannot rest upon it alone. 
!N^ext, have him pass his urine in two glasses, observe 
the mechanism of the act, especially the force and vol- 
ume of the stream, look for prostatic mucus in the first 
urine, put him in the knee-chest position, oil the index 
finger and examine the size, situation and texture of 
the prostate. This is a matter of greatest ease, and 
precision ; note its contour, feel for fluctuation, pain- 
ful areas, etc. ]S"ow place him upon his back, in- 
troduce a soft catheter and determine the presence, 
quantity and quality of residual urine, should such be 
found. With the catheter in the bladder, it is my cus- 
tom to now learn its capacity by filling it with warm 
boric acid solution. ISTow, too, you may estimate the 
thickness of the bladder walls with the finger in the 
rectum and a sound in the bladder, and again observe 
the evacuation of the solution. Here the examination 
for the day should end. A day or two is required for 
recuperation, during this rest order all the urine col- 
lected and measured for twenty-four hours, and have a 
correct record of the hour and number of passages 
necessary to accommodate him. This urine should be 
examined carefully, both chemically and microscop- 
ically and all findings recorded. 

At the next sitting the contour, size and shape of the 
urethral and bladder portions of the gland should be 
determined, all irregularities of the prostatic urethra, 
together with the degree of elongation of this por- 
tion, this can be done by placing the patient upon 
his back, legs slightly flexed and with a flexible bulbous 
bougie (Fig. 43) ; the beginning of the prostatic urethra 
is marked on the stem of the instrument, and by slowly 



156 



GENITO-URINARY SURGERY AND VENEREAL DISEASES. 



coaxing the instrument through this part of the canal^ 
irregularities are noted, as met and passed ; when the 
bulb has entered the bladder a second marking is made 
upon the stem of the instrument and the distance be- 
tween these two will be the length of this part of the 

Fig. 43. 




BLEES-MOQRE INSTRUMENT CO. 



Bougie a Boule linen. 



Fig. 44. 




BLEES-MOORE INSTRUMENT CO. 



Nelaton Catheter. 



urethra. Very often the urethra is so narrowed and 
displaced that neither the JS^elaton catheter (Fig. 44) 
nor the bulbous sound can be made to traverse it, when 
recourse can be had to instruments of different design. 
The most frequent obstruction encountered in pros- 
tatic hypertrophy that calls for attention, is the over- 



HYPERTROPHY OF THE PROSTATE. 157 

growth upward, from the middle portion of the pros- 
tatic urethra, which may exist to a degree absolutely 
blocking the way when instruments of regular pattern 
are used ; this condition is known w^hen a regular sound 
is abruptly arrested as it enters the prostatic portion. 
Such an instrument should be succeeded by one of a 
shorter curve, and introduced by keeping the point 
well against the roof of the urethra, with the view 
of having it over-ride the projection • failing with 
such an instrument the device of Thompson may be 
applied, which consists in removing the stylet from a 
medium English catheter, bend it in a way that it forms 
three-fourths of a circle three and a half inches in di- 
ameter, return the stylet thus curved into the catheter, 
that has been warmed, now place the w^hole into cold 
water until the catheter is temporarily fixed and rigid, 
remove the stylet and introduce the catheter before it 
becomes warm ; the point of an instrument so moulded 
will keep well against the roof of the urethra and may 
pass over the obstruction with ease. 

The instruments of Mercier, Fig. tto, may be used 
in this situation. Fig. 46 illustrates Gross' improved 
catheters ; a stylet, bent to any desired curve or shape, 
can be used with the ordinary soft catheter. The 
jointed catheter has some advantages. Harrison's 
soft, oval bulb bougie has a place, and so w^ith a great 
variety of others. As a rule, it is not difficult to enter 
the bladder ; the instrument that best meets the re- 
quirement is the one to use, until a full knowledge of 
the part is had. Here the greatest gentleness is to 
characterize your manipulations ; it is easy, especially 
with small instruments, to produce a false passage and 
lend difficult complications to an already complicated 
state. When the canal, with its irregularities, has 



158 



GENITO-URINARY SURGERY AND VENEREAL DISEASES. 



been learned, small flexible instruments may be intro- 
duced into the bladder and used as a guide for larger 
and regular shaped ones; 

Prostatic disease or hypertrophy, with bladder dis- 
ease, is an ideal state for the development of stone in 

Fig. 45. 




SILK WOVEN IyE 



>i^. 



.jy?£?. 



^ 



Mercier's catheters. 



the bladder, for which a search should always be made. 
Long continued retention of urine, with dilatation of 
the bladder, atony or sacculi, makes the vicus irregular 
and weak, undue efforts with an instrument is danger- 
ous. The cystoscope can sometimes be used with 



HYPERTROPHY OF THE PROSTATE- 



159 



satisfaction. With this feature of ones duty accom- 
plished, and a diagnosis reached, except there be dis- 
ease of the kidney, a very advanced age, extreme con- 
dition or feeble state of health, the prognosis will be 
full of hope. 

With care and obedience upon the part of such a 
patient, he may be promised great relief of his suffer- 
ing and perhaps years of reasonable activity. 

Fig. 46. 




BLEES-MOORE INSTRUMENT CO. 



Gross' improved. 



Treatment. 

The indications for treatment are : First, the adop- 
tion of those measures that best remedy a mechanical 
obstruction to the expulsion of urine ; and secondly, 
the application of those principles that will overcome^ 
or favorably influence inflammation and disturbance 
incident to pent-up and diseased urine, with the effects 
of over-distention and absorption of effete products. 
Good food (nutritious and digestible), warm, dry feet, 
comfortable and well-ventilated apartments, and a 
urinal within easy reach should first be provided. The 



160 GENITO-URINARY SURGKRY AND VENEREAL DISEASES. 

bowels should be regular; cascara sagrada is an excel- 
lent remedy ; hot rectal mjections once or twice a day 
are well worth the effort (warm water impregnated 
with turpentine is good). The catheter that was found 
applicable should be selected and the bladder daily 
irrigated. When the bladder has been over-distended, 
it is not well to withdraw all the urine at once, for 
fainting, nausea, vomiting, collapse, etc., has resulted 
when an over-distended bladder has been completely 
evacuated. 

It will be well then at this sitting to remove the 
greater part of the urine, moderately fill the bladder 
with some antiseptic solution, have the patient change 
his position, that the heavy urine may be induced to 
leave the low level places and become diluted with the 
solution ; then the catheter is opened and the bladder 
partially emptied. The prostatic urethra is almost in- 
variably diseased and tender ; much service is rendered 
it by introducing the catheter up to this point and fill- 
ing the bladder with the selected solution, having it 
pass directly over, and disinfect this area. As soon as 
a distinct sense of fullness is noticed by the patient, 
the in-flow should be stopped ; it is important to fill 
(without stretching) the organ. On account of ex- 
treme tenderness in the prostatic urethra, it is proper 
to give it some local attention, that treatment of the 
bladder may be carried out with the minimum incon- 
venience. Weak solution of nitrate of silver, one grain 
to the ounce, weak solution of copper sulph., zinc sul. 
permanganate of potash, carbolic acid, tannate of 
glycerine may be applied with a deep urethral syringe. 
The treatment of the bladder is that recommended for 
cystitis. 

Mild antiseptic, and warm sterile solutions, can be used 



hype;rtrophy of the prostate. 161 

in the bladder for the purpose of cleaiihness. Chlori- 
nated soda solution, boric acid, chloride of soda, nitrate 
of silver, ten grains of salicylic acid in an ounce of 
glycerine, and this added to a quart of water. The 
following prescriptions are recommended in prostatic 
hypertrophy, where the obstruction has resulted in 
bladder disease. Rxs. 54, 55, 56 and 57. 

No. 54. No. 56. 

R. — 01. santal ctiv. R. — Salol 5ii- 

Syr. acacise ^iiiss. Peps, sacch -oii- 

M. ft. emul. M. ft. chart No. XX. 

S. — A teaspoonful in water S. — One three times daily, 
four times a day. 

No. 55. No. 57. 

5c.— Spts. terebinth 5iss. I^. — Benzoat ammon qu. 

Pulv. acaciee.. 5i- E^t- hyoseyam gr. iv. 

01. cinnam gtt. xx. Aloin gr. iii. 

Aq. dest gii. M. ft. caps. No. XXX. 

Tr. cardam. co. q. s. ft.giv. S. — One four times daily. 
M. ft. emul. 

S. — A teaspoonful three or 
four times a day. 

There are many methods of irrigating the bladder. 
I do not like the hand syringe, nor the Davidson pat- 
tern, for the reasons that it is easy to use injurious 
force, difficult to obtain a steady stream, easy to inject 
air, and such instruments cannot be readily cleaned. A 
glass douche that can be kept at any desired tempera- 
ture, readily cleaned, one that can be raised to any 
desired height, regulating the force of the stream and 
preventing the admission of air, when the bladder is 
filled, gauging the amount of solution used ; such a 
douche can be lowered below the level of the bladder 
and the fluid syphoned out, which also is marked 
upon the graduated scale. 

Gradual dilatation of this portion of the canal by 



162 GENITO-URINARY SURGERY AND VENEREAI. DISEASES. 

the use of steel sounds run up from time to time to a 
number that distinctly stretches it, is treatment of great 
worth. The hot or cold sound will do much to improve 
nutrition and thereby restore integrity to the part. 
The negative pole of a weak galvanic battery acts 
much in the same way. 

Ergot has been prominently prescribed for hyper- 
trophy of the prostate, and various substances have 
been injected into it, all of which I have repeatedly 
tried with results far from satisfactory. 

With the suggestions here made relative to this 
feature of the treatment of prostatic hypertrophy, one 
may hope to do service so long as the treatment is con- 
tinued. For permanence of results surgery is called 
for. 

I do not believe the value of certain operations upon 
the prostate are fully appreciated, which fact is largely 
due to the erroneous views, and want of clinic con- 
tact, of a class of genito-urinary workers, prominent 
in which list are Thompson, Guyon, Socin and others, 
who believed and taught, that the urinary trouble inci- 
dent to hypertrophy is the result of senile changes in 
the bladder, and not dependent upon the enlarged 
prostate. 

The indications for surgical treatment in prostatic 
subjects are, first, relief of urgent symptoms through 
local means, and general medication ; second, to over- 
come the inconvenience and pain incident to necessary 
treatment ; third, free drainage ; fourth, the perform- 
ance of such surgical operation that best secures a 
correction of the defect that is responsible for the 
suffering. 

If, then, there be developed the so-called third lobe, 
acting as a valve at the neck of the bladder, making 



HYPERTROPHY OF THE PROSTATE. 163 

urination difficult or impossible, a prostatectomy is 
indicated. By this is meant the opening of the 
bladder, either above the symphysis pubis, or through 
the perineum and the fibrous mass enucleated. A 
patient with this form of hypertrophy may be able 
to pass no urine at all in the proper position ; in the 
knee-chest position the flow may start, an effort to 
void it may immediately stop the stream. Such a 
patient was operated upon above the pubes, a pear- 
shape mass, weighing about fifteen drachms, w^as 
removed, with perfect control of the urinary function as 
a result. I believe that this entire class of prostatics can 
and should be dealt with in this way. When a broad- 
ened and thickened mass of tissue constitutes the ob- 
struction, there is no objection to the removal of such 
part as is accessible, and benefit will be proportionate. 
The operation through the perineum, while having the 
advantage of better drainage, and possibly less dan- 
gerous than the high operation, does not afford the 
room ; and the removal of prostatic tissue is more 
difficult and uncertain. The two operations are iden- 
tical in every way with the respective operations for 
stone in the bladder. The prostate is highly vascular, 
and prostatics, as a rule, are in poor condition ; there- 
fore, all w^ork done, should be as rapid as consistent 
with thoroughness, and every precaution should be 
taken against hemorrhage. 

Very good results are had by the establishment of 
a permanent drainage above the pubis, also through 
the perineum ; there are many very competent men 
enthusiastic about this treatment. A few times I have 
drained from above, and many times from below^ ; 
neither has been ideal. Many devices for drainage have 
been recommended ; a low^ level drainage is the desired 



164 GENITO-URINARY SURGERY AND VENTRE AI. DISEASES. 

aim of all such work ; drainage from above the pubes 
certainly does not secure that end. Many times have 
I refrained from doing a prostatectomy on account of 
the debilitated condition of the patient, and have done 
nothing more than a perineal section, cutting deep 
into the substance of the prostate and placing a large 
size tube v^ell down in the cut. I continue this tube 
for several weeks ; every four to six days a large 
sound is introduced into the bladder through the 
meatus, stretching widely the prostatic urethra, 
such drainage enables the bladder to recover from 
the cystitis, and permanent good is almost always ac- 
complished. The introduction of large sounds or 
dilators should be kept up every ten or twelve days for 
an indefinite period. 

Recently double castration for prostatic hypertrophy 
has engaged the attention of surgeons, and very much 
work of this kind has been done. 

Drs. White and Raum have been especially prom- 
inent ; the statistics of White that were reported in 
a recent number of the Annals of Surgery are cer- 
tainly very interesting. The novelty of the operation, 
the number of prostatics, the character of the disease, 
and the ease of operation, led many into this work. 
Enthusiasm ran wild for a time, and many marvelous 
reports filled the journals. I am convinced from my 
own work, and the work of others, that many cases 
have been benefited, a few cured and practically none in- 
jured (in a physical sense) , though mental impairment 
has undoubtedly been due to it in a very few cases. 

To-day, I recommend this operation in those cases 
that fail to be benefited by the local and medicinal 
measures, when the organ is greatly enlarged and in 
such form that no projecting portion exists. 



HYPERTROPHY OF THE PROSTATE. ]65 

Double vasectomy, or ligation of the vasa deferentia, 
means respectively cutting and ligating the vasa defer- 
entia. The result in either situation would be the same ; 
this work is recommended by good authority, and good 
results have been reported. I have done this opera- 
tion when the situation was suited to castration, but 
when the latter was objected to ; it is a very simple 
operation indeed, and is almost devoid of danger. The 
incision recommended for variococele is the one I 
make, the vas, secured and tied in two places, and 
a section removed. Healing is ahvays prompt when 
the usual precautions have been taken. 



CHAPTEE yil. 

CHANCROID — DEFINITION — INCUBATION — ELEMENT IN— CLINIC 
FEATURES OF — FREQUENCY— DIAGNOSIS — PROG- 
NOSIS — COMPLICATIONS — TREATMENT . 

Chancroid. 

Is a highly contagious venereal disease, presenting 
itself in the form of one or more ulcers. In this disease 
there is absent any well-defined period of incubation, 
twenty-four hours to three days is the usual time elaps- 
ing between exposure and the appearance of the sore. 
It is purely a local trouble and is never responsible for 
constitutional disease ; its range of action is confined 
to the infected part or parts, neighboring lymphatic 
glands and the communicating vessels. By many it is 
called soft chancre (a term that is faulty for it is not 
chancre at all) . Many chancres are relatively soft and 
indicate the existence of a disease (syphilis) as differ- 
ent from chancroid as one disease can be from another. 

The infectious element in chancroid, is believed by 
many to be simple pyogenic micro-organisms (or pus 
producing micro-organisms) , that chancroid may 
be produced from acne pustules, or from all sources 
where such microbes are found. For some time this 
position has obtained without question, I freely confess 
that I so taught and believed prior to the last three 
years ; and if it be true that chancroid is due to such 
infection and not to an element of its own, then one 
must doubt his own work and observation. On ac- 
count of limited space any extended discussioil or pre- 



CHANCROID. 167 

sentation of this feature of chancroidal disease, must be 
omitted, T will say, however, that fifteen cases of typi- 
cal chrancroids found upon young men, who at the 
time were suffering from acne, inoculations upon the 
abdomen in two distinct places, one with pus from 
acne, the other with pus from chancroid, thirteen 
chancroid inoculations responded, while only three acne 
inoculations showed any evidence of inflammation , that 
under the same plan of local treatment, all the acne 
lesions were cured speedily, one respectively in four, 
seven and eleven days, that the chancroids healed much 
more slowly, that the sores did not develop alike, did 
not look alike, nor did they behave alike, under like 
circumstances. On account of such work as this, my 
opinion is that chancroid is always dependent upon a 
specific germ found in the secretion of a chancroid. 
IN'otwithstanding our inability at this time to produce 
the chancroid bacteria in pure culture, yet there is at 
hand abundant, and convincing evidence that such ele- 
ment does exist. 

The feature of inoculability of chancroid j)roves its 
local nature and constitutes a valuable aid in differenti- 
ating it from chancre. Any mucous or cutaneous por- 
tion of the body is susceptible to chancroid infection. 
The genitals are most exposed, and any uncleanliness, 
rawness, etc., increases their susceptibility. A chan- 
croid, as it is ordinarily cared for, rarely continues as 
a single sore, for the discharge from the parent sore 
may infect any number of neighboring points, and as 
many chancroids will develop. 

The clinical features of chancroid are displayed 
in table, page 43. Chancroid is seen three times 
where chancre is met once. This is due to the fact 
that chancroid is the more virulent ; that it maybe con- 



168 



GENITO-URINARY SURGERY AND VENEREAL DISEASES. 



tracted any number of times, while it is the rule, to 
which there are few exceptions, that chancre only 
appears once upon an individual. 

The diagnosis of chancroid is not always an easy 
matter. When the history is unreliable, or when the 
lesion has been treated with caustics, sufficient inflam- 
matory induration maybe present to completely change 
the clinic picture (Fig. 47). Its recognition is im- 

FiG. 47. 




Chancroids that have become indurated, due to the application of chloride 

of zinc. 

portant, for the correct interpretation of this disease is 
often the pivotal point upon which the individual's 
future depends. To pronounce a chancroid a chancre, 
and prescribe a syphilitic treatment, when such is not 
indicated, and cloud the life of a patient in this way, is 
a great wrong. To call a chancre chancroid, and deny 
the patient proper treatment for his syphilis, is likewise 
an unpardonable error. In all cases of doubt it is much 
better to delay the diagnosis until the lapse of sufficient 
time to develop corroborative and positive evidence. 



CHANCROID. 



169 



Complications and Prognosis. 

While chancroid is distinctly a local disease, it is 
one that predisposes to a variety of complications, and 
under certain circumstances becomes a matter of much 
moment. 

On account of chancroids about the preputial orifice 
phimosis may ensue, due to inflammation and thicken- 
ing ; or to the production of inelastic scar-tissue after 

Fig. 48. 




Phagedenic Chancroid. 



the lesions have healed ; in like manner paraphimosis 
may result. Lymphangitis often complicates this 
disease. Bubo is frequent, which is painful, extensive 
and followed by suppuration. Gangrene and phag- 
aedena (Fig. 48), involving extensive areas and work- 
ing great destruction, occasionally appears, hence the 
necessity of strict attention to treatment, and a prog- 
nosis duly guarded. 

If, however, a chancroid be encountered upon the 



170 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

person of a healthy individual, and prompt treatment 
be prescribed, the prognosis is very favorable. A cure 
under such circumstances may be expected within ten 
days to three weeks, while chancroid merely protected 
and kept reasonably clean will heal of its own accord 
within three to six weeks. 

Treatment. 

Chancroid is almost invariably of venereal origin ; pro- 
phylaxis consists in the avoidance of sexual contact with 
women of doubtful virtue, and the use of antiseptic washes 
immediately after exposure. Weak solutions of carbolic 
acid, bichloride of mercury, permanganate of potash, and 
pure peroxide of hydrogen mil do much toward prevent- 
ing the development of chancroid. 

When chancroid has developed the treatment may be 
abortive or methodic. By abortion is meant the applica- 
tion of a caustic in such a thorough manner that every 
atom of chancroidal virus is destroyed, and the resulting 
sore will be a simple one, which heals promptly by gran- 
ulation. 

To apply this treatment, the parts should be thoroughly 
washed, the lesion treated to peroxide of hydrogen, then 
to a ten per cent solution of cocaine until anaesthesia is 
complete. Nitric acid, chromic acid, sulphuric acid, chlo- 
ride of zinc or the actual cautery may be used for destruc- 
tion of the element ; every sinus or infected part must be 
reached or failure is sure to follow. After the application 
of the caustic or cautery the sore should be cared for as 
will hereafter be suggested. 

I believe the surest and quickest way to dispose of 
chancroid consists in preparing the parts as above, inject- 
ing a few drops of cocaine near the lesion, then with a 
small, sharp curette remove all trace of the infected tissue ; 



CHANCROID. 171 

now with a stiff brush (a tooth brush answers) and a warm 
solution of bichloride of mercury, vigorously and thor- 
oughly scrub the wound, after which pack with wet bi- 
chloride gauze and inclose with rubber tissue. This treat- 
ment in my hands has yielded most brilliant results. I 
have used it in the beginning of the disease and in those 
stubborn conditions where other treatment failed, or where 
gangrene or phagedsena was present or imminent. The 
dressing should be changed three times daily when this 
form of treatment is adopted. When phimosis exists and 
the chancroid concealed, those situations demanding 
circumcision or the dorsal slit, hesitating to operate 
for fear of infection though the situation demands such 
attention ; I have often operated under these conditions 
without infection of the wound. I curette away, scrub 
the lesions and circumcise, with a stream of warm bichlo- 
ride of mercury solution (1-2000) constantly playing upon 
the field of operation. 

When the abortive measures are not indicated, or when 
objected to by the patient, the methodic treatment may 
be used, which consists in cleansing, and keeping clean 
the lesions and neighboring parts. The sores may be 
cleansed with peroxide of hydrogen or other antiseptic 
solutions and treated with wet or dry antiseptic or astrin- 
gent remedies, the surrounding parts being protected 
against infection. Frequently such sores are extensive 
and painful ; an ideal remedy in such situation is liquid 
campho-phenique ; a pledget of cotton saturated with this 
and packed into such a sore, not only disinfects it and 
stimulates granulation tissue, but calms pain like magic. 
I have often controlled pain with this remedy when co- 
caine failed ; in fact, in these situations it occupies a place 
alone in the therapy. 

As a dry dressing, iodoform is good; owing to its 



172 GENITO-UKINARY vSURGERY AND VENEREAL DISEASES. 

peculiar odor its use is limited, however, which by common 
consent seems to have become associated with venereal 
ulcers. In fact, I believe it an injustice to use this drug 
outside the hospitals and public clinics. A young man 
impregnated with this odor may lose his situation, his 
place in society and perhaps his self-respect. 

Campho-phenique powder, made from carbolic acid, 
camphor, boric acid and acetanilid, is a splendid dry 
dressing ; it has an odor, rather fresh and pleasant, simi- 
lar somewhat to that of the moth ball (used in storing 
away clothing). Aristol is a very nice dry dressing, the 
objection to it being the disposition to form a hard crust, 
w^hich retains the discharge. Calomel, bismuth subni- 
trate, boric acid, oxide of zinc, are- very good. Often the 
parts assume an indolent nature and progress becomes 
arrested ; it is well to apply every second day (after cleans- 
ing) a stimulating application. A solution of sulphate of 
copper, twenty grains to the ounce of water, nitrate of 
silver or sulphate of zinc, fifteen to twenty grains to the 
ounce of water, or what is still better equal parts of 
guaiacol, ichthyol and alcohol. Such applications may 
be made with a camels-hair pencil or with tooth pick and 
cotton. 

The complications of chancroid are treated along gen- 
eral lines, remembering the disposition of all open sur- 
faces to become infected and control of the disease 
lost. If due regard be paid to the details as have been 
previously suggested, namely, thoroughly cleanse, des- 
truction of the lesion with curette or with caustic, scrub- 
bing and washing away all infectious elements, and clos- 
ing all wounds securely, perfect union may be expected 
in a large percentage of cases. 

My recent circumcisions, done in the face of chancroids, 
have shown a remarkable percentage of ideal results. 



CHANCROID. 173 

Nevertheless, it is my advice to delay all such surgery 
when it can be safely done, until the parts are free from 
chancroidal disease. 

About one-third of all chancroid patients develop bubo, 
and whenever suppuration occurs, an opening is either 
made by nature or by the surgeon for the liberation of 
this broken-down material. In either event, there is in- 
flicted upon the patient a compromising scar, a defect or 
blemish, which in after life becomes a source of great 
humiliation. A young wife will inquire about such a 
scar, which will either force a confession or a falsehood. 
In dealing with buboes, regardless of their source, it is 
well to remember the importance of sparing the unfortu- 
nate a scar of this kind. 

At this moment I am convinced that suppuration in 
chancroidal buboes may often be obidated ; rest, the ap- 
plication of cold, and light compression, together mth 
complete and constant disinfection of the sore or sores 
that are responsible, will often succeed. 

I place much greater reliance in disinfection of the 
lesions, and the early injection of the bubo with pure car- 
bolic acid. My notes bearing on this feature of chancroid 
show that suppuration has'been prevented in seventy per 
cent of such cases. Quite often twenty drops of carbolic 
acid has been injected into a large and highly inflamed 
lymphatic gland, in the center of which pus had already 
formed; a week later the gland was removed and the cen- 
ter of the gland was found to be hard and cheesy, with 
suppuration in other parts. Into the center of a small 
and recent bubo, I inject fifteen drops of pure carbolic 
acid; into larger tumors, twenty to thirty drops ; pain is 
relieved at once by it, and very often the tumor ceases to 
enlarge, remains stationary for several days, and then 
slowly disappears ; it may be months before this indurated 



174 GENITO-URINARY SURGERY AND VENEREAI, DISEASES. 

spot is entirely gone. Tincture of iodine may be used to 
paint the bubo. I have yet to be convinced of its value. 
Campho-phenique will often relieve pain and possibly do 
additional good. Equal parts of ichthyol, guaiacol and 
alcohol painted over an inflamed and painful bubo is 
soothing; hot flaxseed poultices, hot water bottles, etc., 
encourage suppuration and relieve pain. 

A bubo may be removed, which is a ready way to cure 
it ; it is much to be preferred to lancing. The skin is in- 
cised over the tumor down to the capsule of the gland, 
the finger detaches the body from the surrounding parts 
and the tumor is lifted out, the part washed and closed ; 
if the gland has broken down, it may be well, after thor- 
ough cleansing, to pack the wound ; bring the gauze out 
the lower angle, then close the wound and remove the gauze 
after twenty-four to forty-eight hours. Often patients 
object to such measures ; when hot applications are made 
until pus forms, which is let out with a bistoury, and the 
poultice continued until suppuration ceases. Chancroid 
is common and severe among the lower classes ; with the 
half -fed and badly kept, the alcoholics, the tuberculous and 
physically depraved it plays sad havoc. When encoun- 
tered under such circumstances, it is important that good 
food and air, good clothing and apartments, tonics, etc., 
be made a conspicuous part of the treatment. The bowels 
should be regulated, sleep secured, and those measures 
instituted that tend to general upbuilding of the physical 
forces. I have used anti-streptococcus serum in the treat- 
ment of chancroid with indifferent results. 



CHAPTER VIII. 

DISEASES OF THE KIDNEY— PYELITIS— HYDRONEPHROSIS— KID- 
NEY STONE— CANCER— PYONEPHROSIS— TUBERCULOSIS- 
SYPHILIS— FLOATING KIDNEY— PERINEPHRITIC 
ABSCESS— TUMORS— NEPHRORRAPHY— 
NEPHRECTOMY— NEPHROTOMY. 

Pyelitis. 

Inflammation of the pelvis and the calices of the kid- 
ney is called Pyelitis. This disturbance may be acute, 
oftener chronic. Like other diseases of the urinary or- 
gans it is dependent upon other conditions for existence. 
Gonorrhoea affords the largest number of acute attacks. 
Any obstruction to the escape of urine or any inflamma- 
tion in the bladder can be responsible. The forma- 
tion of stone in the pelvis of the organ may, by its 
irritating presence, light up inflammation. A small stone 
blocking the ureter, or the same in the bladder, may act 
in a like direction. The occlusion of the ureter in pye- 
litis, from stone or other causes, preventing the escape of 
the fluids from the pelvis of the kidney, resulting in a 
dilated and fluctuating state of the organ, is called pyo- 
nephrosis. Tuberculosis, cancer, hydatid tumors and 
parasites, may be the underlying cause. Pregnancy is 
very often productive of this disease on account of undue 
pressure. 

The turpentine group of drugs, carbuncle, certain forms 
of pyaemia, and some of the eruptive fevers are given as 
causes. The disease may be limited to one kidney, or 
both may be affected. 



176 GENITOURINARY SURGERY AND VENEREAL. DISEASES. 

Symptoms. 

In some communities there is a belief in the mind of 
the laity that all pain in the back, and all disturbances of 
the urinary organs are indications of kidney disease. 
Such an opinion is readily understood, when informed 
that their knowledge is based upon information offered 
by the family almanac, or the literature of the advertising 
quack ; yet my observation of this organ in post-mortem 
work leads me to believe that diseases of the kidney are 
of greater frequency than formerly supposed. 

In pyelitis there is pain and tenderness over the dis- 
eased organ, this pain may be a dull soreness, that is only 
developed from pressure, or it may be sharp and neu- 
ralgic, and reflected some distance beyond the kidney 
area. If the disease be due to kidney stone, usually par- 
oxysms of nephretic colic will have been suffered. The pas- 
sage of a small stone down the ureter, with its sharp and 
angular corners cutting as it goes, will produce pain so 
severe that the patient will be unable to find language 
expressive, he will roll, scream, and may become con- 
vulsed. Following such an attack, there will be blood 
mixed with the urine. If there has been obstruction to 
the kidney the organ becomes enlarged, sacculated, and 
can be easily palpated. The retained pus will express 
itself with chills, fever and sweat, which may resemble 
malaria, but evidences of pyaemia will arise which will 
deepen to a fatal issue, except relief be had. Through 
the urine much information can be had ; it is acid in re- 
action, blood, mucous, round and spindle epithelial cells, 
and traces of albumen are presented. When voided it i& 
heavy, of a uniform greenish, turbid color. When per- 
mitted to stand the pus gravitates to the bottom, the re- 
action remains acid unduly long. When one kidney is 
diseased there may be distinct changes in the urine from 



PYELITIS, HYDRONEPHROSIS. 177 

clay to day. Should the ureter become plugged for a 
time, the clear urine from the healthy kidney would not 
be mixed with the product of its diseased fellow, and the 
urine passed may appear normal. Again, when the kid- 
ney becomes sacculated, relatively the same urine changes 
will occur. Perinephretic abscess may result from such a 
disease of the kidney, especially if due to stone with ob- 
struction, tuberculosis or the presence of parasites. 

Very recently I removed a wasted kidney from a woman 
who had suffered a gradual decline in health for two and 
a half years, on account of a small stone becoming en- 
gaged in the uretral orifice. The tumor had been opened 
in the loin, and an infected fistula remained giving exit to 
pus and urine. The operation was done to overcome the 
septic condition of the patient and rid her of the embar- 
rassment and annoyance resulting from such a fistula. 

The cystoscope is a very valuable aid in diagnosis here. 
With this instrument, and the bladder thoroughly and 
carefully cleaned, the turbid stream of urine from a pye- 
litic kidney can be seen very distinctly as it enters the 
bladder. The claim is made that the ureters may be 
catheterized and the urine collected from either organ. I 
must confess that this is exceedingly difficult in the male, 
though quite easy in the female. The X-ray may be used 
in case of stone. The ureter may become twisted or 
plugged, or some lower portion of the canal may become 
occluded in a variety of ways and produce accumulation 
of urine in the kidney. This may increase until an 
enormous tumor or cyst is present. Such a disease or 
condition is known as Hydronephrosis. 

The urine from a diseased kidney inhabited by parasites 
should be carefully examined microscopically, and opinion 
is to be based upon such evidence. 



178 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

Treatment. . 

When a diagnosis of pyelitis is reached ^ diligent search 
should be made for an underlying cause. Should there 
be urethral, prostatic or bladder disease, the treatment 
suited to such should be prescribed, during which the 
kidney itself should receive such attention as the urgency 
of the situation demands, in all cases rest, regulation of 
diet, stimulation of the skin in the forms of hot baths, 
friction, etc. ; the bowels should be made to assist the skin 
in relieving the kidney of its work. Such remedies as 
benzoate of soda, benzoic acid, salol, borax, etc., may be 
used to stay decomposition and maintain the urine in 
good form. Should the attack be due to a fever, car- 
buncle or other poison, the treatment would be that of 
the original disease augmented by the above. 

Should stone in the pelvis of the kidney or ureter be 
responsible, nephro-lithotomy should be performed. The 
treatment of cysts, pyonephrosis, hydronephrosis and 
perinephritic abscess should be removal of the cause when 
possible, and nephrotomy. 

When tuberculosis of the kidney is suspected, and as- 
surance that the disease is limited to one organ, the other 
being free from all disease (which is exceedingly difficult 
in males), and there is not general tuberculosis, an ex- 
ploratory incision is justified. Should the organ be found 
in such a state, being no longer of service as a urinary 
body, its removal by lumbar nephrectomy is warranted, 
otherwise the usual recommendations of climate, diet, 
etc. The greatest care and conservatism is here called 
for; it has happened that the only kidney was removed, 
or a diseased one left. From the great number of 
worthless kidneys, and the hypertrophied condition of the 
opposite one, found in post-mortem examinations in per- 
sons who died from diseases of various kinds, and who 



SURGERY OF THE KIDNEY. 179 

did not complain of kidney disease, I am well convinced 
that one healthy kidney, properly encouraged, is able and 
willing to perform double service. 

Cancer of the kidney is treated surgically. Nephrec- 
tomy, if done early, and the disease be primary, holds 
out much inducement. The serum treatment in my hands 
for malignant disease of the kidney has failed. 

Other tumors of the kidney require palliation, evacua- 
tion or removal ; their size, nature and symptoms being 
duly considered. 

Surgery of the Kidney. 

Quite an impetus has been given work of this kind in 
recent years. Under strict surgical conditions, with rea- 
sonable care observed, in the selection of cases, the kid- 
ney can be explored, opened, fixed and removed with ease 
and comparative safety. 

The operation of nephrotomy consists in making an 
incision from behind, obliquely forward of three to four 
inches in the ilio-costal space. Beginning in front of the 
erector spinas muscle, and far enough below the last rib 
to avoid the pleura (one-half to one inch), the dissection 
is carried down until the muscular layers are separated, 
the lumbar fiscia is divided and the fatty capsule of the 
kidney is reached 5 this is best torn by forceps or mth the 
fingers. (Adhesions are often numerous and firm), the 
k:idney, if containing pus or other fluid, is now punctured 
with trocar, emptied of its contents, then opened and 
searched, especially for stone. It is better to incise the 
substance of the organ than the pelvis. The opening into 
it should be sufficient to admit a complete search. The 
ureter may be explored if necessary. The edges of the 
organ may be attached to the wound and the part packed 
with gauze, or, if the incision into it has been large, and 



180 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

the integrity of the organ good, with the ureter free, the 
wound in the organ may be closed with a few sutures, the 
field of the operation cleansed, and the whole closed up. 

Nephrectomy. 

By this operation the kidney is removed. It is appli- 
cable in those instances, where nephrotomy has failed, or 
when it is desirable to remove the organ primarily. The 
kidney may be reached through an abdominal incision 
which is best suited for the operation, when cancer or 
other solid tumor of the organ renders it of such size that 
the lumbar route is not sufficient to admit it 5 but for most 
purposes the lumbar is employed, it being easier, more 
simple and less dangerous. (The peritoneum is not 
touched in this latter operation.) An incision very like 
that employed in nephrotomy is made down to the organ, 
a second liberating incision at right angles, and down- 
ward from the posterior beginning of the first incision 
(to gain additional room) may be made if necessary. 
The capsule of the kidney is stripped off with the fingers, 
the organ raised, two ligatures are passed about the ureter, 
and two, including the renal artery and vein, and the 
vessels in this way securely tied in two places. Between 
these two sets of ligatures, the parts are divided, the lig- 
atures cut short and the stumps dropped back, the part 
cleansed, closed, or packed, as the condition suggests. 

Nephrolithotomy. 

Is the operation of removing a stone from the kidney. 
The organ is reached through the lumbar incision de- 
scribed for nephrotomy, the kidney opened through its 
secreting portion, as opposed to the pelvis, and the stone 
removed with fingers or forceps. The after treatment is 
that of nephrotomy. 



FLOATING KIDNEY OR MOVABLE KIDNEY. 181 

Floating Kidney or Movable Kidney. 

While the above terms are used interchangeably, yet 
there is a distinction. The normal position of the kidney 
is behind the peritoneum, and its attachments allow but 
slight moYement. In floating kidney the organ is 
found in the abdominal cavity, and is enclosed in a peri- 
toneal covering called meso nephron. 

Movable kidney is that lax condition of the renal at- 
tachments permitting an undue movement of the organ 
behind the peritoneum. The condition may be inherited 
or acquired, more often the latter. Ninety per cent of 
cases are encountered in women. Tight lacing and child- 
bearing being given as causes; all violent efforts calcu- 
lated to dislodge, or disturb its support, become factors 
in its causation. Tumors dragging it down may' be re- 
sponsible. The symptoms of such displacement are pain 
and nervousness, either, or both of which may be 
paroxysmal or constant. Should a twist in the ureter 
result,- there would be added all the symptoms of occlu- 
sion. For the correction of this state many devices in 
the form of supports have been produced ; rarely is the 
use of such followed by relief. 

Nephrorraphy, an operation for reducing and fixing the 
organ, is usually successful. It is an operation of no 
great danger, and one rather easy to perform. The kid- 
ney is reached through an incision identical with that 
recommended for nephrotomy, the fatty covering treated 
by tearing through, the organ is seized, about four sub- 
stantial silk sutures are passed through its substance, at a 
depth sufficient to hold, and secured to the edges of the 
wound. (Silk worm gut has given excellent satisfaction; 
the sutures are anchored -upon either side of the incision 
with plate and shot, and removed about the twelfth day). 



182 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

Syphilis of the Kidney. 

During the eruptive period of syphilis there may be 
urinary changes that pass away as the eruption de- 
clines, in all respects similar to such disturbances found 
associated with other exanthematous processes. 

Late in the disease the cortical zone can be the seat of 
a gumatous deposit (firm and nodular). There may also 
be found a chronic interstitial inflammation of syphilitic 
origin. 

A diagnosis should be based upon the history, and by 
elimination of those other well recognized conditions that 
resemble it. 

The treatment is that of the original disease. 



CHAPTEK IX. 

STEICTURE OF THE URETHRA — DEFINITION — VARIETIES — 
CAUSES— PATHOLOGY— DIAGNOSIS— TREATMENT- 
COMPLICATIONS. 

From the anatomy of the male urethra it is learned that 
the canal is not of uniform size throughout. Narrow 
places are provided by nature for a purpose. Stricture, 
then, is any unnatural narrowness of this canal. Sir 
Charles Bell has advanced a definition that many prefer: 
''Any lack of dilatability of the urethra is stricture." 
This definition, in the light of modern thought and learn- 
ing, is faulty. 

All strictures may be grouped under two headings, 
spasmodic and organic; the latter may be inherited or 
acquired. 

The form of stricture called spasmodic, while it answers 
the definition; yet it is distinctly different from the 
organic ; it is nothing more or less than the undue exer- 
cise or reaction of the urethral muscles. It is rarely the 
cause of trouble in the sense of stricture. 

There are times when almost every individual expe- 
riences it, or in whom it can be detected, and for which 
treatment is rarely, if ever, indicated. There is good 
authority for the statement that any portion of the 
urethra may be the seat of this form of stricture. I have 
never seen muscular spasm produce obstruction anterior 
to the bulbo-membranous portion. In examinations upon 
persons not accustomed to urethral exploration, it is very 



184 GENITO-URINARY SURGERY AND VENEREAI. DISEASE.S. 

rare not to notice spasm of the cut-off muscles ; indeed, I 
always anticipate a slight pause here; again, the vesical 
sphincter may act in a like manner. 

There are many causes given for the appearance of this 
spasm. The nervous temperament, I am inclined to be- 
lieve, deserves first place, especially those whose sexual 
appointments know no rest or relief. 

Any diseased condition of the urine or urethra, some of 
the reflexes, especially from the rectum. A ligature ap- 
plied to a hemorrhoid has very often excited this muscle 
to a spasmodic state, making urination impossible. 

Fear, shame and modesty will produce it. Young men 
at my clinics, brought into the presence of a class of 
medical students, and even in my private office, will often 
fail to void urine except they retire to an unobserved 
place. 

The treatment mil consist in correcting the trouble that 
underlies the condition. Free purgation may relax the 
spasm. Prescriptions 58 and 59 may be useful: 

No. 58. No. 59. 

5^. — Liq. pot. arsen 3i R- — Stryeh. sulpJi gr. i 

Sodii brom 5i"^ Ext. stramon. pulv gr. xii 

Tr. hyoscyam 3^1 Pulv. ipeeacuan gr. iii 

Aqua cinnam ^iv Pulv. aloin ..gr. vi 

M. ft. sol. M. ft. pil. No. LX. 

S. A teaspoonful in water S. One pill after each meal, 
every two or three hours. 



If the urine is acid, the alkaline diuretics are indicated. 
Very often the sound and sight of a stream of water will 
relieve it. Hot baths, a few drops of cocaine solution 
injected into the urethra may be sufficient-, a hot rectal 
injection is servicable. It may be necessary to pass a 
catheter. 



ORGANIC OR TRUE STRICTURE. 



185 



Organic or True Stricture. 

As before stated, stricture proper may be congenital or 
acquired. Those irregularities that appear at birth as im- 
perf oration or artesia, have been referred to. Any other 
<3ongenita] obstruction, taking the nature of a true strict- 
ure, can be dealt with as though the same had been 
acquired. 

True stricture may be single or multiple ; it may exist in 
the form of a thin narrow partition, with its aperture 
anywhere upon its surface, in which instance it is called 
linear (Fig. 49, A). It may involve more of the urethral 

Fig. 49. 




Organic strictures of the urethra. 

surface, be a thicker or broader obstruction (Fig. 49, B), 
which condition is called annular stricture. A consider- 
able portion of the canal may be taken with such disease, 
the greater part of the urethra, especially that portion 
anterior to the peno-scrotal angle, may become filled with 
a hardened, inelastic tissue, through which the canal may 
run as a narrow, irregular, tortuous passage. This form 
of stricture is called tortuous (Fig. 49, C). A single 
stricture is the rule, two are frequently found, three very 
rarely, and four extremely seldom. 

Dr. Otis has formulated a table which accords with my 
own views, from which a fair idea of the capacity of the 



186 



GENITO-URINARY SURGERY AND VENEREAL DISEASES. 



urethra can be had. Quite often the rule will not be found 
applicable. When the circumference of the flaccid penis 
measures three inches, the urethra should comfortably 
receive a No. 30 French sound; when three and a quarter 
inches in circumference, a No. 32 French sound; when 
three and a half inches in circumference, a No. 34 French 
sound; when three and three-quarters inches in circum- 
ference, a No. 36 French sound; when four inches in 
circumference, a No. 38 French sound, and so increasing 

Fig. 50. 



29 



30 



32 



33 



35 



27 



26 



OOOOOO 



o 



FRENCH SCALE, (approximate.) 



^ -^ I r-1 rl r-i | Ct <?l Ct I (M Qt Ci I CM CJ CI I 01 CO CO CO CO 



c^ a 



•qDoajjf 

•qsTlSna 

'aKouamv 



f^ j Ci CO I "«»< I 
|T-.|(n| }co|-«*«ji«i?o|t«.|oo 



^ ^ tr- |XC50 |— lOfCO l^iO-C 
j<M|COJ'^iOjO| [t^jCCj 



(O. I 



OOOOOOoo 

2^ 21 20 18 17 15 U 12 



o 


2 


O 


3 


O 


5 


O 


f> 


O 


8 


o 


9 


O 


11 



as the circumference increases. Fig. 50 is the French 
scale or measure for urethral instruments. This scale 
also affords a comparison with the English and American 
scales. 

When radical deviations from the table of Dr. Otis are 
discovered, unnatural caliber is in evidence. 

Any portion of the urethra may be the seat of organic 
stricture. About twenty per cent are found in the first 
two and one-half inches of the canal ; about fifteen per 
cent in the next three inches, and about sixty-five per 



CAUSE OF URETHRAL STRICTURE- ' 187 

cent in the remaining portion of the spongy urethra. 
Seldom is stricture found in the membranous or prostatic 
portions of the urethra. 

Pathology. 

The portion of the urethra engaged in stricture may 
show upon examination a hardness, resembling car- 
tilage or cicatricial tissue. Again, the lesion may be a 
thickened and granulating condition of the mucous mem- 
brane ; if more recent still, the site may merely exhibit a 
low grade of inflammation. In all stages of development 
there will be evidence of present or past proliferation of 
connecting tissue- elements, and more or less inflammation 
will- be found either in the mucous membrane or imme- 
diately beneath it, or in both; the resulting lesion will 
be soft, supple or hard. 

Cause of Urethral Stricture. 

From the pathology it is evident that any influence 
capable of exciting inflammation or capable of disturbing 
normal nutrition of any part of the canal, may be the 
cause of stricture. As a factor acting in this direction, 
gonorrhoea is especially prolific; quite seventy-five per 
cent of all the cases of organic stricture are due to it. 
Non-specific urethritis acts in the same way ; being a less 
violent inflammation and running a more rapid course, it 
is proportionately less severe in its consequences. Those 
attacks of gonorrhoea that continue an undue period, 
whether this be the fault of the patient or the treatment 
he receives; situations where chordee, abscesses, congested 
areas, ulcerated patches and the many complications that 
continue the attack, are especially liable to lead to the 
formation of stricture. There is a popular belief that not 
to the disease, but to the remedies used, is stricture due. 
This opinion, while in the main is incorrect, yet any caustic 
injection applied to the urethra, capable of producing 



188 GENITO-URINARY SURGERY AND VENEREAIv DISEASES. 

extreme burning pain that lasts longer than ten minutes, 
is injurious, and any injection that produces hemorrhage, 
or one followed by exfoliation of mucous membrane, in 
criminal^ for certainly such applications can and do pro- 
duce a cell proliferation, ending in stricture. Prolonged 
and unrelieved congestion occurring in young men whose 
minds are ever upon matters sexual, may cause stricture. 

Electricity employed within the urethra, for various 
purposes, has resulted in stricture. Within the past year 
I have performed urethrotomy, either internal or external, 
at least eight times for very extensive and firmly indu- 
rated strictures that I had every right to believe was due 
to galvanism of the urethra, the cases being typical rep- 
resentatives of the neurasthenic class, in whonj there had 
never been urethral disease, and five of whom no sexual 
relations had ever been indulged in. 

Traumatism furnishes its quota ; breaking the chord in 
chordee; while not practiced to-day to its former extent, 
nevertheless means a stricture for each offense. That 
portion of the canal passing through the triangular liga- 
ment is especially liable to injury. Falling astride a 
carriage wheel, kicks or blows upon the perineum, any 
form of violence that is inflicted or bears upon the urethra 
can be responsible for stricture. Whenever a stricture of 
the membranous urethra exists, a traumatic history 
should be expected. The improper use of surgical instru- 
ments have been known to produce stricture. 

The two most interesting traumatisms that I have 
treated were cases, first, where .a man in oiling overhead 
machinery, slipped and fell astride a set of revolving cog 
wheels, the penis became engaged together with the 
scrotum, the greater part of both destroyed and the 
urethra cut in two places. External urethrotomy suc- 
ceeded in saving the parts, though a second operation for 



CAUSE OF URETHRAL STRICTURE. 189 

stricture was necessary a year afterward. Three years 
have passed and the patient can pass a No. 20 French 
sound, which he does every two weeks. 

The second case was that of a farmer while in a stoop- 
ing position (repairing his scythe), his hired hand, who 
was mowing from behind, struck him with the point of 
his scythe, laying open the posterior portion of both 
thighs, the point of the scythe dipping in and cutting 
off the urethra posterior to the scrotum. The urethra 
was opened in this case behind the transverse cut, and the 
scythe wound approximated, after union of which the 
longitudinal incision was permitted to close and sounds 
passed every fourth day. In the face of close watchful- 
ness by his family physician, contraction of the scythe 
wound progressed; at eleven months from date of in- 
jury the largest instrument that could be passed was a 
No. 18 French. At this time stricture complications in 
the form of bladder inflammation developed and a second 
external urethrotomy was done. A year and a half has 
now passed since this last operation and I am assured 
that there is no trouble. A No. 31 French sound is now 
used without difficulty. 

The different vocations of man make it impossible to 
individually mention all the types of injury possible here, 
that may result in organic stricture. 

The time required for stricture to develop to an extent 
that attracts attention, is variable, especially when due to 
gonorrhoea. An attack of this disease may not be termi- 
nated before stricture has started, and become responsible 
for the prolonged discharge. About fifty per cent of 
strictures develop during the first year following urethral 
disease, about twenty-five per cent during the second year 
and the remaining twenty-five per cent develop later, some 
recorded as late as twenty-five years. Injuries that are to 



190 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

result in stricture, do so at much earlier jDeriods; if an in- 
jury is done the urethra and there is no resulting obstruc-. 
tions within six months, the patient is rather secure 
against the development of stricture. Strictures, whether 
due to urethral disease or traumatism, may be Resilient 
or Irritable. These qualitative terms mean respectively 
elastic (behaving as if made of rubber), or irritable (ex- 
citable) ; should an instrument be passed through a resil- 
ient stricture, it would at once contract to its former or 
even smaller size. Should an instrument enter an irrit- 
able stricture, it would be sensitive, it would inflame, and 
be made worse on account of such treatment. 

Symptoms of Stricture of the Urethra. 

Not every stricture is attended by symptoms. A strict- 
ure of moderate tightness may exist, the urinary and gen- 
eral health may continue good, and no knowledge or notice 
of its presence is had. While this is undoubtedly true, 
and many have lived a life time and died of other diseases, 
not being aware of urethral obstruction, yet the existence 
of a stricture, no matter how trivial it may appear, is a 
constant menace to good health and longevity, and the 
possessor is never safe from consequences most serious. 
It is usual, however, for such sufferers to be annoyed 
though the subjective symptoms are not constant; there 
may be pains of a neuralgic nature in the penis, perineum, 
back and bladder, if the stricture be so pronounced as to 
call for great effort in forcing the urine through. 

This straining may provoke a fullness of the hemor- 
rhoidal vessels and an attack of piles or prolapse of the 
rectum be brought on. Hernia might result from the 
same cause. 

A blue and pale appearance of the meatus is frequently 
noticed where stricture is present, due to the disturbance 



SYMPTOMS OF STRICTURE OF THE URETHRA. 191 

of circulation. A mucoid or gleety discharge is rather a 
constant symptom. Shreads passed with the first urine, 
which fall to the bottom of the glass, are rather constant 
in stricture. Hard areas at the site of stricture, the sex- 
ual organs are affected, the stream of urine is diminished 
in size and is twisted, ejaculated semen is not delivered in 
normal jets, but remains posterior to the obstruction to 
find its way out, little by little, or with the urine. As 
the obstruction advances the straining is increased, the 
urethra, immediately behind the stricture, becomes di- 
lated on account of the great pressure of the urine against 
the lesion, a few drops of urine remaining, develop am- 
monia products, inflammation of the part takes place in 
consequence of this decomposed urine, the mouth of the 
urethral follicles are opened as the urethra is stretched, 
unclean matter finds lodgment and a septic process is de- 
veloped therein. Inflammation travels backward, infect- 
ing in turn the areas invaded, the neck of the bladder 
and deep urethra are attacked ; there will now be urgent 
and constant desire to pass water, the bladder proper may 
become involved, trabeculse, sacculation or contraction of 
the bladder by inflammatory thickening may result. 
Should retention of urine occur, which is always in order, 
the bladder may become over-distended; if unrelieved, 
paralysis and dilatation is to be feared. Such a state as 
this greatly jeopardizes the kidneys. Many attacks of 
pyelitis have an origin of ^ this kind. The urine is always 
altered; aside from the shreads resembling cob-webs, 
ivhich soon sink to the bottom of the glass, mucus, pus 
and blood are rather constant attendants to a well ad- 
vanced stricture that has^developed cystitis. 

Complications. 
As a result of stricture, all parts of the uro-genital or- 
ganization may be directly or indirectly diseased, and 



192 



GKNITO-URINARY SURGERY AND VENEREAL DISEASES. 



what has been said in regard to the spread of the infec- 
tious agents to all these parts , applies as well here. Rup- 
ture of the urethra, followed by extravasation of urine, is 
a complication that often entails much suffering and dis- 
figurement. The urethra, behind a narrow stricture, is 

Fig. 51. 




Gangrene, following infiltration of urine, due to rupture of the 
urethra from stricture. 



dilated by forcible efforts at urination, its walls become 
thinner and correspondingly weaker. The infected folli- 
cles found in such a location favoring, until the walls can 
no longer resist the pressure and rupture follows, the re- 
gion about the urethra becomes filled not only with urine, 
but with the unclean products, containing ammonia salts ^ 



DIAGNOSIS OF URETHRAL STRICTURE. 193 

bacteria, pus, blood, etc. Very soon the integrity of the 
parts invaded by this offensive material begin a process 
of tissue necrosis, and a slough with loss of substance 
proportionate to the extent of the infiltrated area takes 
place. Fig. 51 is just such a case. Fistulse follow in the 
course of such destruction. A fistula may also develop 
from abcess formation in the diseased and open follicles ; 
at first there is a drop of pus, the pressure of the urine 
and nature of the inflammatory extension carry it deeper 
and deeper until the urethral walls have been penetrated. 
The little abscess may point and open, leaving a fistula 
marking its course; occasionally several follicles pur- 
sue such a course and numerous fistulse result. 

Infiltrated urine may locate itself in a number of places ; 
it may be confined within the limits of Buck's fascia and 
if the urine be free from unclean matter, it may remain in 
this location without producing much damage for many 
days, or it may present near the corona glandis and leave 
a fistula opening here. It may leave the urethra posterior 
to the triangular ligament, and pass into the pelvic cavity ; 
or anterior t6 the triangular ligament and present in the 
perineum or scrotum. Such complications demand very 
prompt and active measures. Liberating incisions, to 
divest the parts of their hurtful occupants, thorough 
cleanliness, warmth to prevent all possible gangrene, ex- 
ternal urethrotomy, tonics, stimulants, the best food and 
hygienic surroundings. Stone in the bladder is often due 
to stricture. 

Diagnosis. 

A patient will perhaps complain of a slight but persist- 
ent discharge, a narrowed or irregular stream, irritability 
of the bladder, an uneasy feeling in the urethra or any of 
the symptoms previously enumerated. He will give a 



194 GENITOURINARY SURGERY AND VENEREAL DISEASES. 

history of urethral disease, traumatism or some form of 
disturbance, yet with all the symptoms of stricture com- 
plained of, and a perfect history of urethral disturbance, 
the surgeon is not justified in making a diagnosis of strict- 
ure, no matter how complete the case may seem. History 
and symptoms are sendcable only so far as directing the 
attention to the parts, a diagnosis rests wholly upon ure- 
thral instrumentation. The examination now indicated 
should be arranged for and conducted in the following 
manner : 

Fig. 52. 




BLEES-MOORE INSTRUMENT CO. 

Bulbous Sound. 
Fig. 53. 





BLEES-MOORE INSTRUMENT CO. 

Conical Steel Sound. 



Certain instruments become a necessity, a very few 
simple ones will answer the purpose of deciding whether 
or not a stricture is present. In fact, a single medium- 
sized English catheter very often is all that is required to 
gain this knowledge. It is important in such situations, 
not only to know if there be a stricture, but all other im- 
portant facts. 

The size, the texture, the extent, resiliency, or irrita- 
bility if such exist, and for the accomplishment of such 
investigation the following instruments should be at hand 



DIAGNOSIS OF URETHRAI, STRICTURE;. 



195 



and in a state of surgical cleanliness f a set of bulbous 
sounds (Fig. 52), ranging from No. 10 to No. 30 (French 
scale), a set of steel sounds (Fig. 53), of similar sizes, a 

Fig. 54. 




BLEES-MOORE INSTRUMENT CO. 

Otis' Urethrameter. 
Fig. 55. 



J 



/^- 



BLEES-MOORE INSTRUMENT CO. 

Whalebone Filiform Bougies. 
Fig. 56. 




BLEES-MOORE INSTRUMENT CO. 

Gou ley's Tunnelled Catheter. 
Fig. 57. 



BLEES-MOORE INSTRUMENT CO. 

Tunnelled Catheter. 



urethrameter (Otis pattern) (Fig. 54), is a convenient one; 
ordinary French flexible bougies, several sizes, ranging 
from No. 4 to No. 20; at least half a dozen filiform whale- 
bone bougies (Fig. 55), at least three sizes tunnelled 



196 



GENITO-URINARY SURGERY AND VENEREAL DISEASES. 



sounds and catheters (Figs. 56-7-8) Nos. 8, 12 and 
20, French; a deep urethral syringe (Fig. 59), an 
ounce of a five per cent solution of cocaine, and a 
tube of sterilized vaseline. With the bladder empty and 
the urethra cleaned, the patient is put upon his back, 

Fig. 58. 




BLEES-MOORE INSTRUMENT CO. 

Gouley's Tunnelled Sound and Guide. 
Fig. 59. 





BLEES-MOOBE INSTRUMENT CO. 

Deep Urethral Syringe. 
Fig. 60. 




BLEES-MOORE INSTRUMENT CO. 



Piffard's Meatometer. 



legs slightly separated, the meatus is measured with a mea- 
tometer (Fig. 60), and a flexible stem bulbous sound 
(tested to see if the bulb is securely fastened to the stem) 
of a size that the meatus will comfortably take, is selected. 



DIAGNOSIS OF URETHRAL STRICTURE. 197 

this is oiled and slowly passed down the urethra. When 
the pendulous urethra has been traversed and the curved 
urethra reached, it is expected that resistance will be met 
by the action of the muscles in this region, again its 
progress may be arrested, due to the instrument being 
straight ; here the canal is curved and demands that suf- 
ficient pressure be applied to the flexible stem to force it 
into the curve. 

The fingers of the left hand may follow the bulb of the 
instrument the entire way, the object being to elevate the 
bulb as it enters the deep urethra (thereby having the 
stem curve upon itself to meet the urethral curve.) 

The finger on the outside, elevating the bulb with pres- 
sure upon the stem, forces the instrument into proper form 
and the remaining journey to the bladder is accomplished. 
As the instrument is withdrawn, the action of the vesical 
sphincter, and the compressor urethrse muscles will be 
very distinct, and so with all irregularities encountered. 
With a roomy meatus, if a No. 25 bougie will pass, 
a No. 30 steel sound should be applied, which will more 
readily enter the bladder than the first instrument ; should 
this instrument pass, then a full size sound should be 
used, if this latter instrument be received by the urethra, 
it justifies the opinion that no stricture exists. Should 
the first instrument be arrested at the beginning of the 
fixed urethra and reasonable coaxing fails to have it go 
deeper, a conical steel sound of equal size should be used 
and after diligent effort (not force) it fails a smaller size 
should be tried, say a No. 20, should this fail to enter a 
J^o. 15, soft, olive-tipped bougie should be tried; this fail- 
ing, smaller sizes in turn may be tried, scaling down to the 
filiform if necessary. When the bulbous sound has failed 
to pass this or any other portion of the canal under such 
manipulation, the diagnosis of stricture is reached. If a 



198 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

No. 25 bulbous sound fails and a No. 25 conical steel in- 
strument succeeds, we conclude that the opposition to the 
first was muscular spasm, which was overcome by the sec- 
ond instrument. If the meatus will take a No. 32 sound 
and an obstruction is found that will not admit a No. 25 
or No. 30 flexible stem bulbous bougie, but will receive a 
No. 25 conical steel sound and no larger, we know that 
there is both muscular and organic stricture. Now, if a 
No. 20 flexible bulbous bougie is selected and passed 
through the obstruction, the behavior of the bulb while in 
relation to the stricture, which is manifested through the 
sense of touch and observance of the stem, both in pass- 
ing over it and its halting, and jumping movements, while 
withdrawing, affords a very clear idea of the extent and 
character of the lesion. The urethrameter may be con- 
veniently used for this purpose, especially when the meatus 
is small, adjusting it to a size that will pass all obstruc- 
tions and noting the indicator as it engages in the strict- 
ure. What has been said relative to obstruction of the 
urethra in this region applies to all other parts of the 
canal. Muscular stricture is only to be considered in the 
region of the compressor muscles, all other constricted 
areas which may in this way be detected are organic. 

The meatus is the smallest part of the canal. If the 
meatus readily receives a No. -32 sound, and some deeper 
portion of the urethra will only admit a No. 25 or No. 28, 
though the difference be a slight one, a stricture is diag- 
nosed. Should an average penis with a small meatus (the 
meatus having been cut to No. 35) receive with comfort a 
No. 32 or No. 33 sound for one or two inches and at a 
deeper point the instrument be unable to pass, but one a 
few sizes smaller does pass, then, too, will there be a 
stricture. In a word, when by the proper use of the in- 
struments mentioned, an area of unnatural narrowness of 



TREATMENT OF URETHRAL STRICTURE. 199 

the urethral canal is found, the diagnosis of stricture is a 
fact, and unless obstruction be actually located by such 
means, such disease cannot positively be said to exist. 
Treatment of Urethral Stricture. 

In this field fads, fancies and fanaticism are clearly 
attributes of our profession. Very much Vork has been 
done highly tinctured with sentimentalism. Almost every- 
body claims, hopes and presumes to be competent to 
treat stricture of the urethra, and there are very many 
who never refer such cases to proper sources until a time 
when they are no longer able to content them. Many 
shining meteors from the uro-genital firmament have 
quickened into the dazzling, shot into space, sizzled, sput- 
tered, and had their fuse burnt out just as the world had 
retired to a safe distance and become ready to look on with 
wonder, such has been the enthusiasm of one class ; while 
the pendulum of the other has swung back to a low con- 
servatism, and as a result the two superlatives stand star- 
ing at each other. The essentials for proper treatment of 
this condition demands a satisfactory knowledge of the 
anatomy and physiology of the parts involved. Their 
condition in health and disease should be known. 

The pathology of stricture and those complications that 
render this subject so deserving of understanding should 
have been studied. All workers in a given cause must 
of necessity live for a greater or lesser time in the forma- 
tive, realm. It is unfortunate that the first efforts of so 
many, is the invention of a new urethrotome, the over- 
throw of older ideas, or the construction of new and rad- 
ical plans for the cure of stricture of the urethra, for in 
this connection there can be no stereotyped rule ; each 
case is a study and should be met with recommendations 
that are reasonable. I have been induced to try almost 
everything that bore the slighest evidence of merit, and 



200 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

have thus far continued unbiased in my conclusions. I 
am therefore prepared to give it as my opinion that there 
are no urethral injections that in the least, favor the dis- 
appearance of stricture, no direct application of powders, 
or ointments, that will be of service, no supposito- 
ries can be depended upon and no mineral waters have 
the power to melt them away. I am sure that there are 
several ways of disposing of stricture, methods that are 
safe, and when properly carried out return results most 
brilliant. I believe stricture of the urethra, wherever sit- 
uated, regardless of its cause or extent, can always be 
benefited and often perfectly cured The armamentarium 
of the surgeon doing this work need not be so extensive, 
but such operations should not be undertaken without 
proper pro^dsion, those devices that will be referred to in 
this chapter are imperative. Strictures of the urethra can 
often be cured by gradual dilatation, by this is meant the 
regular and prolonged use of the conical steel sound. 
Strictures anywhere in the canal that have not become 
firmly organized, not irritable, or resilent and not at the 
time the cause for much suffering, are often best treated 
by the use of the sound gradually run up to the full size, 
thus if stricture be diagnosed and a No. 12 or No. 15 soft 
catheter will pass, a No. 15 or No. 20 steel sound will be 
received. 

Should this amount of instrumentation be followed by 
comfort, there being no hemorrhage and no material in- 
convenience in voiding urine after the first day, a No. 22 
sound may be passed on the fourth day. Should soreness 
continue three or four days after urethral manipulation, 
or there be some blood passed with the urine, it is best to 
prolong the interval between the applications. Usually 
every four to eight days is proper, thus by a gradual in- 



tre;atme;nt of urethral stricture 



201 



Fig. 61. crease in the size of the sound, the ure- 

thra in the course of five to twelve months 
may be brought to a state of health. 

When the largest sound that is to be 
used has been reached, which will usually 
be a No. 30 to No. 33 (which will require 
two to three months), this particular one 
should be continued (lengthening the in- 
tervals as the urethra may allow) for at 
least three months after all disposition to 
recontr action of the strictured area is 
passed. 

The advantages of this treatment are, 
that it is simple and if the instruments 
used are clean it is perfectly safe ; it will 
neither confine the patient to his bed 
nor detain him from his vocation, the 
disadvantage being the time necessary 
to complete a cure. 

Treatment by divulsion or breaking 
the stricture is an operation less popular 
to-day than previously. It consists in 
passing a divulsor through the strictured 
area and so using the instrument that 
rapid and full stretching or even tearing 
the stricture results. Bigelow^s divul- 
sor is used by first passing a filiform 
bougie into the bladder, with this as a 
guide, the filiform is attached to the 
staff of the divulsor which latter follows 
the course of the former; upon this 
staff an appropriate divulsor is guided 
Oouiev's Dilator. down the urethra and through the strict- 



202 GKNITO-URINARY SURGKRY AND VKNEREAI, DISEASES. 

ure with steady pressure. Several sizes of the divulsor 
are made and the operation is complete when the full 
size is used. 

Steam's and Grouley's divulsors (Fig. 61) are used 
either with or without the filiform guide; they are 
quite small when closed and unless the opening through 
the stricture be ,very small or irregular, the guide is un- 
necessary. The same precaution against making false 
passage should be taken, and unless the surgeon be very 
familiar with this subject, it would perhaps be safer ta 
work with a guide. With such an instrument through 
the stricture, the guide may be withdrawn and the blades 
of the instrument slowly opened. When the desired de- 
gree of divulsion is reached, do not make the mistake so 
common to amateurs in letting down the instrument (even 
a little before removing) , for if this should be done the 
lining membrane of the urethra falls between the blades; 
it is tightly grasped, and the instrument cannot be re- 
moved without stripping of this tissue which would be the 
starting point of traumatic stricture. 

It is very seldom that I use these instruments for the 
treatment of stricture. . This operation is indefinite in 
the anterior urethra ; I use divulsors with much satis- 
faction when the stricture is too narrow to admit a 
proper cutting instrument ; the opening can be readily 
widened with them. 

Electrolysis. 

Being forced to notice the wonderful claims made 
for electrolysis (or curing stricture by electricity), and 
having a number of cases that insisted upon this new 
treatment; contrary to my best judgment, I pro- 
vided myself with a most approved electric outfit and 
became ready to waive all prejudice. (The term sounds 



EI.ECTROLYSIS, URETHROTOMY. 203 

well; it appeals to the masses.) With ten well se- 
lected cases my work began ; there appeared to be much 
benefit in eight ; two did not do so well. The treatment 
was faithfully carried out and the following conclu- 
sions reached : The mind improved in ninety per cent 
for the first few days of treatment ; in sixty per cent an 
improvement of the part resulted, equal to the improve- 
ment following the use of a steel sound the size of the 
electrode, and forty per cent were made worse. I have 
no confidence, whatever, in this method of treatment. 
Gralvanism, however mild, has no resolving, or absorb- 
ing influence upon an organic stricture ; but, on the 
contrary, its action, if applied in appreciable currents, 
is in essentially the same direction as that of the usual 
causes of stricture (i. e., inducing cell proliferation). 

Urethrotomy. 

Is the treatment of stricture of the urethra by cut- 
ting, the operation done within the canal is called In- 
ternal Urethrotomy, and the operation done from with- 
out is called External Urethrotomy. 

The instruments designed for internal urethrotomy 
are called urethrotoms, of which there is a great variety. 
Strictures at or near the meatus can be divided with 
a probe-pointed bistoury, or with an instrument called 
a meatome. A strictured or narrowed meatus should 
be cut upon the floor in the line of the median raphe ; 
all other strictures found in the pendulous urethra 
should be cut upon the roof, precisely in the center. 
Strictures of the bulbous or deeper urethra should be 
cut from the outside, consequently upon the floor of 
the canal. 

The operation of internal urethrotomy consists in 
having all surgical details of preparation carried out. 



204 GKNITO-URINARY SURGERY AND VENEREAL DISEASES. 

The patient should be prepared for a few days by hav- 
ing his general health brought up to a fair standard ; 
his urine should be examined in advance, and if un- 
natural, the best efforts to correct it should be em- 
ployed. 

Those remedies recommended for cystitis may 
be of service if the condition be urgent ; it is often 
impossible to have an ideal state. The freshly cut sur- 
face is to come in contact with the urine ; healthy 
urine is an elegant tonic ; decomposed urine is a poison, 
hence the necessity of having the urine slightly acid 
and free from hurtful products. 

With such a patient upon his back, the area may be 
anaesthetized with cocaine in this manner. Ten drops 
of ten per cent solution are drawn into a deep urethral 
syj-inge, the point carried to the face of the stricture, a 
small rubber catheter is tied around the penis one-half 
inch anterior to the point of the syringe (which will be 
one-half inch anterior to the stricture) ; the rubber is 
applied just tight enough to confine the drug to the 
desired area, and loose enough to permit circulation in 
the penis. In ten minutes the part is insensible to 
pain, otherwise ether or chloroform narcosis is em- 
ployed. 

If the stricture be tight and only a filiform will enter, 
it may be stretched as described under divulsion ; the 
object is to permit a urethrotome to pass, failing 
to satisfactorily divulse, the urethrotome may be 
threaded upon the filiform guide and pushed to the de- 
sired depth. The situation of the stricture should 
be carefully measured and this marked on the urethro- 
tome (with reference to the position of the blade when 
produced) . This is done that the exact knowledge of 
the knife to the lesion can be had. The closed ureth- 



URETHROTOMY. 205 

rotome, with knife concealed, is lubricated with carbo- 
lized glycerine or oil and slowly introduced. The 
presence of the obstruction is noticed as the point 
passes, when the knife of the instrument is just be- 
yond the stricture (which is known by the mark 
previously made, and also the position of its remote 
end). The instrument is now adjusted with the cut- 
ting edge of the knife in the median line upon the roof 
of the urethra ; now the knife is exposed with its edge 
in relation to the stricture, the urethrotome is slowly 
opened, gradually forcing the cutting edge deeper and 
deeper into the strictured tissue until a size has been 
reached equal to the natural calibre of the canal. If it 
is believed that the stricture zone is broader than the 
free cutting edge of the knife, it is proper, as the dilat- 
ing is advanced, to drag the knife through and divide 
all such material. When the required cutting is 
finished, the knife is concealed and the instrument 
withdrawn (without letting down its blades). A bulb- 
ous sound about two sizes smaller than the cut strict- 
ure is now lubricated and passed beyond the cut, and 
all irregularities noted with its withdrawal. A full size 
steel sound is now passed to the bladder, and the oper- 
ation is completed by passing a catheter and washing 
out the bladder. This operation is rarely followed by 
hemorrhage of any consequence. The free surface of 
the knife in most instruments is such that a cut beyond 
the coats of the urethra can hardly be made. Heckles 
surgery can inflict a cut beyond, or through the parts, 
and hemorrhage rather profuse will follow. This can 
readily be controlled by ice, pressure on the outside, or 
by a sound on the inside, or with both. Occasionally, 
on account of excessive cutting, the cavernous substance 
is reached, when hemorrhage and a deformity of the penis 



206 



GENITO-URINARY SURGERY AND V^NEIREAI, DISEASES. 



when erect may result. Such a patient should be put 
to bed for a few days. Diseased urine may be drawn 
through a catheter, otherwise it should be voided in the 
natural manner. This operation can be done at home, 
or most anywhere, the urethra being a shut canal, 
infection is no more liable one place than another, if 
the operation be clean throughout. The after treat- 
ment is the use of full-sized sounds, beginning on the 
fourth day following the operation and repeating about 
once a week thereafter for a month, then at longer in- 
tervals until the part has thoroughly healed. A sound 
should be used a few times a year, for a long time, to 
make sure that there is no evidence of return of the 
stricture. fig. 62. 



^::^ 




Wyeth's modified Otis urethrotome. 
Fig. 63. 




Gouley's dilating urethrotome. 
Fig. 64. 





BLEES-MOORE INSTRUMENT CO. 

Gross' curved urethrotome. 



EXTERNAI. URETHROTOMY. 207 

External Urethrotomy. 

This is an operation for stricture in the deep urethra, 
and any obstruction, traumatic or otherwise, found in 
this region, ft is often done to secure rest and drain- 
age of the bladder, for infiltrated urine, small calculi, 
growths at the neck of the bladder, etc. There are 
four operations known ; with one exception all are easy 
of performance, relatively simple and safe. There 
is little difficulty when some form of a guide can be 
used. When it is impossible to even use a filiform for 
this purpose, in those long-standing cases where fis- 
tulas exist, where the canal is filled with pathologic 
material and has lost all resemblance of its real self ; 
it is under such conditions as this that external ureth- 
rotomy becomes one of the most difficult operations in 
the domain of surgery. 

The simplest, and the operation in this region that 
is oftenest done, is when the obstruction will admit of 
a grooved staff (Fig. 65) . 

With the patient surgically prepared, squarely upon 
his back and anaesthetized, the staff is introduced and 
the patient placed in the lithotomy position (Fig. 66) . 
An assistant steadies the staff, making its convex and 
grooved portion press out the perineum, and at the 
same time holds up the scrotum. The median perineal 
raphe is the site for the incision which should extend 
from the posterior scrotal angle dowmw^ard toward the 
rectum for about two inches ; the integument and 
deeper tissues are carefully divided down to the urethra, 
the groove in the staff is now detected with the finger 
and an opening into it of one-half to three-fourths of 
an inch (depending upon the amount of stricture tis- 
sue to be divided) is made, through which a lS[o. 33 or 
'No. 35 soft rubber catheter is passed into the bladder 



208 



GENITO-URINARY SURGERY AND VENEREAI. DISEASES. 



which now may be washed and inspected for stone or 
other disease. A full-size sound should be passed 
through the meatus to the bladder. 

Fig. 65. 





BLEES-MOORE INSTRUMENT CO. 

Mason's catheter stafiP. 



Fig. 66. 




Lithotomy position. 

The catheter should be passed through the pe- 
rineal wound and arranged so its eye is just within 
the bladder; it is often pushed well up toward the 



EXTERNAL URETHROTOMY. 209 

fundus, in which situation drainage and rest is not 
had, and the object of the operation, and the benefits 
anticipated are defeated. This perineal drainage is 
fixed in this position with a suture, including the in- 
tegument from either side, the wound is now washed 
and packed with gauze, the patient put to bed and the 
drainage attached to rubber tubing, ending in a bottle 
beside the bed containing a solution of carbolic acid. 
The urine from the kidneys will now pass into the blad- 
der on through the perineal drain, down the rubber 
tubing into the disinfected receiver. 

Ordinarily the bladder should be washed through this 
drainage (after disconnecting the rubber tubing) twice 
a day with boric acid solution or some appropriate 
antiseptic. The perineal drainage-tube should be re- 
moved every three or four days, cleaned and returned. 
Usually it can be removed permanently on the eighth 
to twelfth day when full-sized sounds should be used 
at intervals of once aAveek. The perineal opening be- 
gins to close of its own accord upon the removal of the 
drainage, and the urine will be passed normally after 
three to ten days. From a clean operation, a fistula is 
not to be feared. Any additional treatment may be 
directed on general lines to meet existing conditions. 
The patient can leave the bed on the day following the 
removal of the tube. The wound should be protected 
with antiseptic dressing, held in place with a T band- 
age, until repair is complete. When the incision in 
this operation is made in the median line there is little 
hemorrhage, no vessels will require a ligature ; if the 
incision is inclined to the side, the artery of the bulb 
of the urethra may be cut and some difficulty may be 
had in ligating it. At times this vessel is found in the 
median line and cannot be avoided. 



210 GENITO-URINARY SURGKRY AND VENEREAI. DISEASES. 

The operation known as Gouley's and Wheelhouse's 
differ somewhat from the above. In the former we 
have to do with a stricture so small and so tortuous as 
will only admit a filiform bougie. With the patient 
prepared, placed and anaesthetized, as in the above 
operation, the filiform is passed into the bladder. Over 
this, as a guide, Gouley's tunnelled catheter staff 
is passed down to the stricture. 

This instrument and the scrotum are managed as 
before. An incision in the perineum identical with 
that just described, except carrying it nearer to the 
anus, making it two and a half inches in length, is 
made down to the urethra, the groove in the catheter 
staff is located with the finger-nail, a bistoury is passed 
through the urethra into the groove and a cut toward 
the rectum an inch in length is made. It is to be re- 
membered that in this groove is the filiform guide ; 
care should be taken lest it be cut. The surgeon 
should have all anatomical bearings clearly before him, 
the bistoury should puncture the urethra only in a 
single place and the cut made free and clear. A liga- 
ture is now to be passed through both edges of the 
open urethra, made long enough to serve as retract- 
ors (but little tension should be applied lest they cut 
through and wound the part) . ^ow the catheter staff 
is pulled slightly forward, the handle manipulated in 
conjunction with the retractors, the black filiform will 
be seen. An Arnott's director (Fig. 67) is entered 
alongside the filiform and passed into the bladder ; be- 
ing sure of this, the filiform may be removed. In the 
groove of the director Gouley's bistoury (Fig. 68) is 
entered and passed through the strictured zone, cut- 
ting freely and clearly as it goes, the director with the 
bistoury is turned to the opposite direction and as the 



e;xte;rnaIv urethrotomy. 



211 



knife is withdrawn this part of the stricture is cut. 
The probe pointed gorget of Teale (Fig. 69) may be 
substituted for the small director when the opening- 
through the stricture will permit its passage. The 



Fig. 6- 




Arnott's grooved director 



Fig. 68. 



Gouley's beaked bistoury. 
Fig. 69. 




BLEES-MOORE INSTRUMENT CO. 

Teale 's probe -pointed gorget. 

finger may now be gently pushed into the bladder, 
after which the viscus should be washed, explored and 
cared for as directed in the previous operation. 

The Wheelhouse operation is identical mth the last, 
with these modifications. It is done in those cases 



212 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

where it has been found impossible to even pass a fili- 
form (such cases are very rare) ; if the urine, even in 
the smallest quantity, can find its way through ; dili- 
gence and perseverance will succeed in insinuating a 
filiform. The class of cases where it is impossible to 
do this is where fistulous openings exist, and the urethra 
completely blocked. Before abandoning hope of suc- 
cess with the filiform, the various shapes of this in- 
strument should be tried. The canal down to the 
stricture may be filled with olive oil and manip- 
ulated, a dozen or more filiforms may be placed and 
jostled about the surface of the stricture hoping one 
may enter ; in short, the last and most earnest effort 
on the part of the surgeon should be the passage of 

Fig. 70. 



■=^ 



BLEES-MOORE INSTRUMENT CO. 

Wheelhouse's urethrotomy staff. 



the filiform. When no guide is possible, the patient 
is prepared as before. Ether narcosis is engaged, a 
Wheelhouse staff (Fig. 70) is passed down to the 
stricture with the groove upon the floor of the urethra, 
the patient is put in the lithotomy position. This staff 
and the scrotum is taken charge of by an assistant, a 
favorable light and plenty of time provided. The 
surgeon seated upon a low stool with the light di- 
rectly upon the field of operation, an incision is care- 
fully made as before directed, possibly extending to 
within one-half inch of the anus, the urethra is reached 
and opened in the groove which will be anterior to the 
stricture. This opening should be large enough to 
receive the hooked extremity of the staff as it is turned 



EXTERNAL URETHROTOMY. 213 

over. Now tlie angle of the urethra will be engaged 
with this hook, and the incision in the urethra should 
be carried back to the face of the obstruction. The 
sides of the cut urethra are retracted, either with for- 
ceps or by sutures, and the surgeon looks directly upon 
the obstructed area hoping to find the opening. 

There may be much that is pathologic, and the pic- 
ture before him may not appear to offer any aperture 
whatever ; of all times it is now that coolness and 
method be practiced ; the small probe-pointed director 
of Arnott may be used to explore, or any suitable in- 
strument ; Walker's knife (Fig. 71) is ser\dceable. It 
may be that no difficulty will attach to this search, or 

Fig. 71. 



l^^^^^^^^^^^^^P 



BLEES-MOORE INSTRUMENT CO. 



Walker's knife. 



it may be that two hours or even a second sitting may 
be necessary in locating the opening. 

Personally, I have often been placed in such a posi- 
tion, but fortunately I have thus far succeeded without 
undue delay. Knowledge of anatomy is essential, and 
too great haste may often cause confusion and delay. 
When the opening is found the operation is finished 
in all respects as the previous. The after treatment 
should be modified to meet individual requirements. 
Cases that demand this operation are very chronic, 
and many times fistulse exist which should be opened, 
curetted and packed. 

The Cox operation is one of so limited application 
that it will be passed. 



CHAPTEE X. 

STONE IN THE BLADDER— DEFINITION— CAUSES— SYMPTOMS- 
DIAGNOSIS— TREATMENT . 

Stone in the urinary bladder (as indicated " by its 
name) , is a concretion made up for the most part of the 
normal constituents of the urine which may be the 
oxalates, urates, phosphates, etc., collected about some 
foreign substance found in the bladder and offering it- 
self as a nucleus. Thus a clot of blood, a piece of 
catheter, a shot, fragment of bone, a hairpin, a small 
stone, from the kidney, or any object whatever that is 
rolled about in the bladder may begin collecting the uri- 
nary salts, mucus, pus, etc., irritating the organ more 
and more as it increases, and making the condition fav- 
orable to its rapid formation. 

Occasionally a small concretion leaves the bladder 
and enters the urethra and becomes lodged. It may 
ulcerate its way out or it may continue its development, 
to be removed later. 

Certain sections of the country favor the formation 
of stone. My native State, Kentucky, furnishes a 
large number, so with Tennessee, Virginia, etc., no 
doubt on account of the water and diet. Any diet that 
brings the urine to an alkaline condition, any disease 
or obstruction to the free evacuation of the bladder, 
acts in the direction favorable to stone formation. 
Bladder stones may be of such small size as to cause 
but little trouble or may completely occupy the viscus. 
They may form rapidly or their growth may be very 
slow indeed. I will briefly refer to two cases, illustra- 



STONE IN THE BIvADDER. 215 

tive of the differences displayed in the same disease, 
and will further show how easy it is to err except dili- 
gence and method attend such examinations. 

October 13th, 1889, J. H. consulted me about his 
little son, Mike H., aged eleven years. The history 
he gave was everything or anything. To produce it 
here would require many pages. In substance, he said 
that three years previous the little boy began to com- 
plain when he passed water, that he was taken to his 
family physician , whom I know to be a pleasant homeo- 
path, that during these three years this little fellow had 
grown worse from week to week, that an abscess had 
formed in his perineum, broken and the urine had 
adopted this fistulous tract ; on account of the pain he 
had pulled at the penis so long and hard that the 
doctor had concluded his trouble was due to a long- 
prepuce and recommended circumcision which was 
done. This operation was only an additional compli- 
cation. The little sufferer continued to pull at it, in- 
fection, followed by suppuration, to an extent that his 
entire genitals looked necrotic. To make life endura- 
ble morphine had been given for at least two years. 
At this time his daily dosage was eight powders of one 
grain each. Even in his extreme condition, emaciated, 
septic, his body full of pain and with prayers for 
death, it was difficult to overcome the prejudice in the 
mother's mind against the old-school doctor. My 
presence was unwelcome, notwithstanding a diagnosis 
was made of stone in the bladder under great diffi- 
culties (the urethra being closed, the fistulous open- 
ings were taken advantage of, and with a slender probe 
the stone was reached.) An effort was now made to 
improve the condition of the patient, his pain being so 
great and infection so extensive, it was found impossi- 



216 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

ble to succeed. October 22, 1889, the patient was 
etherized and hurriedly prepared. The stone was of 
such size that it was impossible to deliter it through a 
perineal opening, a supra-pubic incision was made, as 
will be described later, and a stone, weighing upward 
of two and one-half ounces extracted. I was never 
able to give the patient any after attention. In a few 
days improvement began, and I was informed that the 
little fellow wished his former attendant to care for 
him, to which I was forced to consent. A month later 
the bladder and perineum had healed and the boy was 
rapidly gaining weight and strength. I was told by 
his father that no opiate had been used since the oper- 
ation. Eleven months later I was consulted by the 
father, who told me that Mike was complaining again. 
I had him brought to my office, chloroformed and ex- 
amined and stone diagnosed. I proposed a second 
operation while the condition was favorable, but litera- 
ture from mineral springs was so convincing, that my 
services were declined and lithia water was used. Dur- 
ing the next month the symptoms developed so rapidly 
that the case was placed in my charge (with many 
apologies for lack of appreciation, etc.) The previ- 
ous operation having been so successful it was decided 
that October 22nd (which was the first anniversary) 
should be the time for the second operation. On this 
date, 1890, the bladder was opened above the pubis, a 
stone, weighing one ounce and one-half dram, was re- 
moved, and the usual after-care given with a perfect 
result, the patient to-day being a perfect specimen of 
physical strength. 

The second case is that of Mr. C. H. Y., age sixty- 
eight years, who had complained of bladder disease 
since the age of twenty-seven, had passed blood, pus, 



STONE IN THE BLA.DDER. 217 

etc., at intervals, and displayed all the symptoms of 
stone for a number of years. For relief of retention 
urine, I was called by his regular attendant, at which 
time his history was learned and the presence of stone 
detected. Left perineal lithotomy was performed with 
good results, when a stone, weighing two and one- 
half drams, was removed, the center of which was a 
«hot that was received nineteen years before through 
the accidental discharge of a gun. 

From these two cases will be learned that the time 
necessary for the formation of stone is very variable 
and the symptoms may, in like manner, vary in char- 
acter and degree. 

Symptoms of 5tone in the Bladder. 

With an understanding of the nature and function 
of the bladder, the causes and conditions leading to 
stone formation, the change in size and situation as the 
organ is filled or emptied, leads to a very clear under- 
standing of the attendant symptoms. Pain is perhaps 
the most constant and pronounced of all. This pain 
will be slight when the stone is small, its exterior 
smooth and the integrity of the bladder good, and 
more severe when the conditions are reversed. This 
pain will be greatest when the body is jolted, as in 
riding and running, as opposed to rest. It will be 
paroxysmal at times. It will be developed as the urine 
is voided and the vesical sphincter grasps it. 

The disturbance of urination will be measured by the 
above, thus if the stone be angular and irregular, when 
grasped as the bladder is emptied the parts will be 
wounded, and blood will be passed with the last urine, 
pain will be greater and cystitis will develop more 
readily. If of a shape to act as a valve to the vesical 



218 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

neck the stream will be suddenly arrested and a change 
in position will be necessary to complete the act. Re- 
flected pain to the end of the penis is frequent, some 
relief is had when the member is squeezed or pulled, 
this is very constant in the young, and often leads to 
masturbation, and an elongated condition of the penis. 
The urine will be found to show evidence both of the 
changes leading to stone, and the morbid condition re- 
sulting from the presence of the stone. All the symp- 
toms of cystitis will be a part of the scene, hsematuria, 
history of renal colic or obstruction, to the urinary 
passages may be expected. 

Diag-nosis. 

From the history, symptoms and clinic picture offered 
by the patient much presumptive evidence is had and a 
diagnosis should be undertaken along these lines. 
Every avenue leading in this direction should be ex- 
plored and due weight attached to all information 
found, but it is left to a physical examination to say 
whether or not stone exists. With this exploration and 

Fig. 72. 



SE 



BLEES-MOORE INSTRUMENT CO. 

Thompson's stone searcher. 

examination of the bladder, even though all else in this 
connection be omitted, a correct conclusion is readily 
had. With proper preparation, a patient suspected of 
having stone should be placed upon his back, hips 
slightly raised and with four to eight ounces of fluid in 
the bladder, my preference is warm, normal salt solu- 
tion. A Thompson stone searcher (Fig. 72), or some 
short, curved instrument, is introduced to the fundus 



STONE IN THE BI.ADDER. 



2J9 



of the bladder where it is gently rotated, making the 
instrument touch every part; it is now withdrawn 
shghtly and a similar movement is made, this order is 
continued until the entire organ has been searched. 

Where the prostate has elevated the bladder neck 
making a depression (^'bas-fond) of the bladder," it is 
especially important to so manipulate the short, curved 
instrument that this pouch be explored ; it is the lowest 
part where a foreign body will find its way by gravity, 
and here it would rest with the greatest comfort. 

Fig. 73. 




BLEES-MOORE INSTRUMENT CO. 



Nitze-Leiter eystoscope. 

If a stone is met by the instrument, it will be recog- 
nized either by the click or the grating sensation trans- 
mitted to the hand through the polished instrument. 
Some dwell upon the difficulty of finding a stone ; from 
personal experience, I am inclined to believe this a very 
easy matter. Such an examination will also admit an 
approximation of the size of a stone and an estimate of 
its hardness, both of which are important when decid- 
ing upon treatment. 



220 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

The cystoscope (Fig. 73), is a most useful instru- 
ment here ; it may be used, a stone located and its size 
and composition determined. 

So important an instrument demands more than a 
passing mention, while a detailed account of its many 
advantages cannot be produced in a work of this kind, 
yet enough may be offered to convey a fair idea of its 
usefulness. 

This instrument consists of a series of lenses, a win- 
dow either upon its concave or convex extremity, and a 
small incandescent electric lamp, as shown in the cut. 
It is a most ingenious optical arrangement, about the 
size of a No. 25 French sound, and is to be introduced 
into the bladder, as a sound. 

There are several patterns, the window may be upon 
the anterior part of the shaft or in the posterior, there 
is a pattern provided with an irrigating catheter, and a 
catheter to be introduced into the ureters, and one ar- 
ranged for the removal of growths within the bladder. 
To use the instrument the patient should be upon his 
back, thighs apart, legs elevated, with his buttocks 
slightly over-hanging the edge of the table. 

The urethra should be anaesthetized with cocaine, the 
bladder thoroughly cleansed and containing four to six 
ounces of normal salt solution, the cystoscope is intro- 
duced carefully, passing the angle well within the 
viscus, the light which is furnished from a storage, or 
fluid battery (having been previously tested) is turned 
on, the surgeon seated upon a low stool between the 
patient's thighs, begins the work of examining, this is 
done by changing the position of the instrument as the 
search progresses, until the inspection is complete. 
Many recommend injecting quite a quantity of cocaine 
solution into the bladder. I have found that it does no 



STONE IN THE BLADDER. 221 

good ; applied to the urethra it serves the purpose of 
conducting such an examination with reasonable dis- 
comfort. 

The lamp in most instruments gets quite hot and care 
should be taken that it is not held in contact with the 
bladder or the urethra, it should be extinguished be- 
fore the instrument is removed. Much practice with 
this instrument is necessary, at least two patterns are 
required for a complete examination. 

The X-ray may be serviceable. I have used it in 
two cases only, and in neither would I be willing to 
rest a diagnosis upon its evidence ; the difficulty is in 
the shadow of the pelvic and spinal bones eclipsing the 
stone. 

Treatment. 

The treatment to be advised in a given case should 
be that which promises the surest and safest results 
with the least probability of return. I am convinced 
that it is a waste of time to aim to dissolve a stone by 
mineral waters, by medicine taken or injected into the 
bladder, although much good, no doubt, could be ac- 
complished in this direction had we the power to fore- 
see the future of our patients. Unfortunately we never 
know the patient has a stone until it is there, and are 
therefore unable to prescribe prophylaxis. We should 
cure a stricture and so deal with the results of it that 
a favorable state for stone formation be not left, the 
same is true of prostatic disease, and all other diseases 
obstructing the parts. All gouty or rheumatic subjects 
should have their diet, exercise, etc., so regulated that 
concentration of the urine would not arise. The liver, 
skin and digestive organs should be considered, but all 
this is not applicable to a stone in the bladder. 



222 GENITO-URINARY SURGERY AND VENERKAI. DISEASES. 

A short while ago much emphasis was placed upon 
certain articles of food, meats and sugar; it has been 
the trend of modern thought at least, to attach less 
weight to such minor matters, and at this moment I am 
inclined to think that in health as well as in disease, 
the uncorrupted appetite or craving is the best guide 
to follow in the selection of our food. If we live upon 
the animal and vegetable products maturing and ripen- 
mg about us, those things of which we are fond and 
prepared in a manner acceptable to the palate and 
agreeable to the stomach, we need look no further in 
this direction. 

In the matter then of disposing of stone in the 
bladder, medicine, diet, and change of climate, have 
no place, and the choice is between palliation or op- 
eration. 

If the patient be of extreme age, and the suffering 
resulting from a bladder stone be slight, it is perhaps 
the better part of wisdom to care for such a case by 
looking after his comfort and general health and so 
long as such measures succeed no operation will be 
indicated. Should the possessor of stone be suffering 
from other disease, not directly due to such a foreign 
body, namely, organic kidney or heart disease, it may 
be well to content such patients with palliation. 

In all situations when the comfort of the patient is 
sacrificed or when the health is declining in conse- 
quence of a stone, an operation is not only indicated 
but demanded. 

The preparation of a patient for this operation dif- 
fers somewhat from the usual surgical case. The 
bladder and the urethra are almost invariably diseased 
and the treatment for cystitis should be employed to 
prepare it for surgical manipulation. 



Fig. 74. 




STONE IN THE BI^ADDER. 223 

There is offered a choice of several methods 
for removal of the stone. The bladder may 
be entered through the perineum or above the 
pubis, or the stone may be crushed while in 
the bladder and washed away in small frag- 
ments. 



Utholapaxy (or the Crushing Operation). 

This operation is the favorite with many 
and for several reasons presents strong claims 
for general favor. It cannot be done upon 
male children on account of the small size 
of the urethra. It cannot be done where 
there is stricture ; the same is true with most 
forms of prostatic hypertrophy or other ure- 
thral obstruction. Large or hard stone can- 
not be safely treated, nor do I believe it 
should be done when there is extensive disease 
of the bladder ; in fact, the usual conditions 
causing stone and the diseased areas due to it, 
together with the uncertainty of the results, 
develop the conclusion that litholapaxy will 
soon be classed with its predecessor, lithotrity, 
which latter has long since passed into obli- 
vion. This operation is one of the remaining 
surgical operations that is done from first to 
last in the dark, the result of which you can 
never be sure. In the light of modern thought 
and understanding there can be but one future 
for all such methods. The instruments nec- 
essary for the performance of this operation 
are a lithotrite (Fig. 74) with which to seize 
nthXite. a;nd crush the stone, a wash bottle, or evac- 




224 



GENITO-URINARY SURGKRY AND VENEREAL DISEASES. 



uator (Fig. 75) and a series of tubes to flush the 
bladder and wash away the debris, the result of the 
lithotrite. 

The patient is prepared, etherized, placed upon his 
back, with hips slightly raised, about four ounces of 
boric acid solution is thrown into the bladder ; the 
lithotrite is introduced, the stone touched (which will 



Fig. 75. 




BLEES-MOORE INSTRUMENT CO. 

Bigelow's evaeuator and tubes. 

be upon the floor), the instrument is turned one-half 
around (jaws up) and the jaws opened by means of 
the attachment at the handle ; it is now (with open 
jaws) turned back and the stone grasped and crushed, 
(to always do this and spare the bladder walls requires^ 
skill that few possess) . The larger fragments are in 
turn treated in this manner until the stone has been so 
treated that all its parts will pass through the tube. 



STONE IN THE BLADDER. 225 

The lithotrite is now removed and a tube (full size) 
either straight or curved, is entered, the wash bottle 
attached, and the broken stone removed. Should any 
fragments remain, after washing, the lithotrite is to 
be used as before and the bladder again washed. 
Should the tube become plugged an obturator should 
be used. Care should be taken that the tube when 
withdrawn holds no portion of the stone in its eye to 
injure the urethra. The ineffectual work done upon 
the cadaver, the feeling of uncertainty following this 
method upon real cases, the anxiety and fear of blad- 
der injury forces the profoundest respect for those 
who have the skill to always so manage such cases 
and do no injury. 

Lateral Lithotomy 

Is the operation for stone in the bladder through an 
incision in the perineum. This is clearly mentioned in our 
most ancient literature. It has always been considered 
a serious undertaking, and even to-day the mortality 
is relatively high. The fact that the mortality in this 
operation is slightly greater than in the operation of 
litholapaxy seems to be an argument that is incontro- 
vertible. Evidently, sight is lost of the fact that 
litholapaxy is onl}^ done where there is no stricture or 
obstruction, consequently little disease of the bladder, 
urethra and kidneys ; it is only done where the stone 
is small and soft ; it is not done on children ; and it 
is in all these extreme conditions where lithotomy has 
a place ; upon the badly diseased, and dying as it were. 
Is it any wonder that there should be a slight differ- 
ence in the mortality? I have not yet seen a case of 
stone where the urethra and bladder were in good con- 
dition ; the organs are almost invariably septic and in 



226 



GENITO-URINARY SURGERY AND VENEREAI^ DISEASES. 



form to be improved by free drainage. All things 
considered, the indications for lithotomy are far more 
numerous than for litholapaxy. 

Fig. 76. 




Lithotomy position. 
Fig. 77. 





BLEES-MOORE INSTRUMENT CO. 



Little's lithotomy staff. 

The perineal incision is indicated when the stone is 
small, when there is stricture and obstruction, and 
when drainage is desired. 



STONE IN THE BLADDER. 227 

The patient is prepared, placed in the lithotomy 
position (Fig. 76) , with good light directly upon the 
field of operation. The lithotomy staff (Fig. 77) is 
introduced into the bladder, with its point against the 
stone and there held by an assistant, with the instru- 
ments in charge of a second assistant and, at easy 
reach, the surgeon seated upon a low stool facing his 
work. The assistant upon the left of the patient in 
charge of the staff, now draws up and slightly out- 
ward, hooking the point of the staff under the sym- 
physis and having the convex grooved portion promi- 
nent in the perineum (the scrotum being held up) . 

A survey of the premises is now calmly taken, the 
finger is inserted in the rectum to make sure of the re- 
lations, the tuber ischii are observed. Noav it is that 
perineal anatomy must be known. 

Clearly refreshed by the hurried consideration of the 
landmarks, the operator once more glances at his assist- 
ants, sees that the staff is correctly and firmly held, 
with one stroke of the scalpel, beginning one and one- 
fourth inches anterior to the anus and one-third of an 
inch to the left of the median raphe, outward and down- 
ward for two and one-half to three inches, ending mid- 
way between the tuberosity of the ischium and rectum. 
With this first cut the parts are divided to a level with 
the urethra (many surgeons prefer to open the urethra 
with this first incision. I have tried both an equal 
number of times, and am convinced that the proper 
opening is best made as above suggested) . The bulb 
of the urethra is now pushed aside, the, scalpel passed 
through the urethra into the groove of the staff (mak- 
ing but one opening) . The knife (Fig. 78, with its back 
occupying the groove of the staff) is pushed along the 
groove in a horizontal position until its point enters the 



228 



GSNITO-URINARY SURGERY AND VENEREAL DISEASES. 



neck of the bladder. ^N'ow the knife (with its point 
held in relation to the staff) is made to describe an 
angle of thirty to forty-five degrees by lowering its 
handle. The cutting edge is directed in the line of 
the first incision and in this position it is withdrawn, 
cutting all the while, to a degree that will admit of the 
removal of the stone. The finger is now insinuated 



Fig. 78. 



m 






mtm^^s 



Blizzard's lithotomy knife. 



Fig. 79. 




Lithotomy forceps (straight). 
Fig. 80. 




BLEES-MOORE INSTRUMENT CO. 

Lithotomy forceps (curved) . 

into the bladder along the staff, which latter is now 
withdrawn. The stone is seized with forceps (Figs. 79 
and 80) and extracted without bruising the parts. Its 
delivery should be with the utmost gentleness, always 
with its smallest diameter. Should this incision fail to 
accommodate, a similar but shorter cut can be made 
upon the other side. 



STONE IN THE BLADDER. 229 

The Median Operation 

is essentially the same as the above, except (as its 
name implies), is in the median line. Stones less than 
an inch in their largest diameter may be removed by 
the median cut. Stones from one to two inches in 
their largest diameter through the lateral, but larger 
stones should be removed through the supra-pubic 
wound. 

Supra=Pubic Cystotomy. 

This operation is indicated for large, or encysted 
stones, bladder tumors, etc. ; it affords a perfect in- 
spection of the organ and when done under favorable 
circumstances is relatively safe. The patient prepared 
and etherized, the bladder comfortably filled with 
boric acid solution, the patient is placed in the Tren- 
delenburg position (which means upon the back, the 
liips raised on an inclined plane fifteen to eighteen 
inches above the shoulders, the legs together). An 
incision three inches long is made in the linea alba, 
beginning three-fourths of an inch from the symphysis 
pubis and extending toward the umbilicus ; this is 
carried to the recti muscles, which are now separated 
with the handle of the scalpel, and held apart by small 
blunt retractors. The tissues are now separated down 
to the pre-vesical fat, which should be pushed toward 
the peritoneal fold, the distended bladder is now in 
view ; it is transfixed (I prefer passing a large curved 
needle armed with a substantial double suture) ; a 
sharp and narrow bistoury is entered, with and in ad- 
vance of the index finger, and the fluid of the organ 
is in this way retained. The incision into the organ 
should now be made of such size as will meet the re- 
quirements of the operation, the stone is grasped and 



230 GENITO-URINARY SURGKRY AND VENEREAL DISEASES. 

removed. If the bladder is found to be in a healthy 
condition, I close its wound with cat gut and the ab- 
dominal with silk, leaving a small gauze drainage in 
the lower angle of the latter. Should the bladder (as 
it usually is) be found inflamed, it is best to insert a 
rubber drainage at its lower angle, close its remaining* 
portion and leave the outer wound open, the Avhole 
packed with gauze. Some surgeons make no effort 
to close either ; I have often acted in this way, but 
now, much prefer partial or complete closure. The 
after treatment of all operations of the bladder should 
consist in keeping the i3arts clean and at rest. 



CHAPTER XI. 



DISTURBANCES OF URINATION — PHYSIOLOGY OF URINATION — 
URGENT URINATION — DIFFICULT URINATION— INVOLUN- 
TARY URINATION— RETENTION OF URINE— HEMA- 
TURIA— PNEUMATURIA— NORMAL CONSTIT - 
UENTS OF URINE — URINARY 
EXAMINATION. 

Physiologic Urination. 

By virtue of the pressure within the Malphigian 
corpuscles (Fig. 81), the urine is extracted from the 
blood, aided no doubt by muscular action of the urinif- 
erous tubules ; the urine finds its way into the pelvis of 
the kidney, thence by the action of gravity, together 
with uretral muscular movement, it passes into the 
bladder. The normal kidneys of the healthy adult 

Fig. 81. 




Malphigian corpuscles. 

should produce about forty to sixty ounces -of urine 
in each twenty-four hours. The healthy bladder, 
after receiving fourteen to sixteen ounces, is distend- 
ed; now by its nerve. endowment there is created a de- 
sire to dispose of its contents. This first impression 
is forwarded from the neck of the bladder to the cere- 
bral center J which in turn communicates with, and 



232 GENITO-URINARY SURGE;RY AND VENEREAL DISEASES. 

orders its subordinates to prepare ; through this com- 
mand the diaphragm and abdominal muscles join in 
action with the sphincter muscles and the stream is 
started. Thus far the act is governed indirectly by 
the head center ; now the involuntary center (or the 
bladder center) is placed in charge and the act com- 
pleted as such. When the remaining quantity is so 
small that the bladder fails to complete the task, the 
voluntary center again calls into action the diaphragm 
and abdominal muscles, which now spasmodically and 
in jets force out what remains. 

There is yet a small quantity in the urethra which is 
pressed upon by the urethral and perineal muscles, and 
ejected. Still anterior and beyond the reach of the 
action of these latter muscles there is in the canal a 
few drops which are forced out by a wave of blood 
upon the outside, coursing downward and pressing the 
sides of the urethra together, thus disposing of the 
last few drops. The number of times this act is per- 
formed in health varies somewhat, owing to diet, sea- 
son, exercise and condition of the blood ; ordinarily, 
an individual should void his urine four to six times in 
twenty-four hours. 

Urgent Urination. 

There are many who suffer embarrassment and pain 
on account of a sudden and pressing desire to pass 
urine ; knowing their inability to curb the desire or 
stay the act, this condition is one deserving of men- 
tion ; true it is that such a state is but an indication of 
disease, near or remote, and treatment of the underly- 
ing cause is recommended. Yet such a cause is so 
obscured that it is impossible to detect it at times and 
rational treatment cannot be had. As just indicated, 



URGENT URINATION, DIFFICULT URINATION. 233 

it is the opinion of the author that the nerves at the 
vesical neck stand as sentinels, always mindful of the 
bladder's welfare and ready to announce its pleasure to 
the superior center and await further orders ; that 
disturbances of this kind always depend upon impres- 
sions here, or in parts directly associated. Proof of 
this belief is always at hand ; pass an instrument here 
and there is always awakened such a desire ; the finger 
in the rectum will accomplish the same, if this part be 
disturbed ; therefore, the physician should look for 
such conditions as create disturbance in this situation ; 
he should examine for posterior urethral disease ] should 
see that the urine is normal in quality and quantity ; he 
should test the capacity of the bladder ; should regu- 
late diet, exercise and clothing ; look well to the con- 
dition of the nervous system. Tumors or foreign 
bodies pressing upon the parts should be considered 
and treatment should be appropriate to such findings. 

No. 58. No. 59. 

R. — Fl. ex. rhus. aromat ^i I^- — ^1- ^x. tritici. ripens ....^i 

Fl. ex. belladon 3i Fl. ex. valerianas %\ 

Potass, nitras 5iss Spts. menth. pip \ ^.. 



Fl. ex. cascara aromat ....gi Spts. ammon. ar.. 

Tr. Cubebse %\\ Syr. aurant. cort giss 



M. 



M. 



S. A teaspoonful in water S. A teaspoonful in water 

every three or four hours. every three or four hours. 

Difficult Urination. 

Very often complaint will be made that the urine is 
voided with great difficulty, that niuch straining is 
necessary to start the stream, that once begun little 
trouble is had. The thought previously developed 
holds good here ; in these situations the involuntary 
part of the act is wanting; the act requires the ex- 
treme effort of the diaphragm and abdominal muscles ; 



234 GENITO-URINARY SURGERY AND VENEREAI. DISEASES. 

the sentinel at the vesical neck is either off duty, 
asleep or dead ; the impulse is received and transmitted 
in an indifferent manner, the very opposite of the situ- 
ation in urgent urination. Such cases may be relieved 
by arousing the proper centers by sight or sound of 
running water, anything that will bring into the cir- 
cuit the proper center, an instrument into the urethra, 
finger in the rectum with pressure upon the vesical 
neck. Such a condition suggests sluggish nerve re- 
sponse and an investigation properly made in this di- 
rection will usually locate the fault. Anxiety, fear 
and modesty often, momentarily, cause such a disturb- 
ance. 

No. 60. No. 61. 

R. — Zinci phosphidum gr. iii I}l. — Ext. ergotse pulv gr. xxx 

Strych. sul gr. i Aloin gr. v 

Quininae sul gr. xxxvi Ex. hyoseyam gr. vi 

M. ft. pil. No. XXXVI. M. ft. pil. No. XXX. 

S. One three times daily. S. One four times a day. 

Electricity, hot and cold baths, friction, diuretic and 
tonic remedies will be indicated. 

Involuntary Urination. 

The passage of urine without the consent of the indi- 
vidual is a condition common to infantile and childhood 
life. It is also found in the nocturnal type in adult life 
occasionally. Infants are prepared for such accidents 
and no attention is paid to them. 

If the trouble continues into childhood there may be no 
disease, no chorea, no diathesis, the child being vigorous 
and healthy, the fault may be the force of habit acquired 
through inattention on the part of the parent. The diet of 
the infant is fluid, the bladder small, restraint has not 
been taught and such incontinence is natural. When in- 
continence continues, the habit of attending to the blad- 



INVOLUNTARY URINATION, RETENTION OF URINE. 235 

der should receive attention, the individual should be 
given little fluid in the evening, the skin should be fric- 
tioned, the bowels opened, the diet digestible, he should 
be awakened at stated intervals which should be length- 
ened twenty minutes each night, all harsh measures 
should be discontinued and the moments of sleep should 
be sound, he should be kept warm and comfortable. The 
nerves should be toned and quieted. 

No. 62. No. 63. 

R.— Tr. cantharides 11>x R.— Fl. ex. belladon 3^ 

Liq. potass, arsen TlJ-xxxii Fl. ex. sennae 5ii 

Kali, brom '^iv Syr. prun. virgin ^iiss 

Elix. simplex ^iv M. 

M. ft. sol. S. Ten to twenty drops 

S. Ten to fifty drops, ac- every two to four hours 

cording to age, every four until effect of the bella- 

to six hours in water. donna is noticed. 

Collodion over the meatus, blisters to the perineum and 
all the forms of punishment recommended does harm and 
stands as a menace to good returns. Very often I have 
seen the condition made worse by such measures and 
cured by the adoption of the opposite. 

Incontinence, in adults, may mean a contracted blad- 
der, a diseased nervous system with paralysis; it may 
mean overflow, due to urethral obstruction ; it may come 
as a result of retiring after excessive indulgence in beer. 
In any case attention is called to such conditions, and 
treatment will be dependent upon the causes. 

Retention of Urine. 

In this condition the bladder becomes filled and there 
is inability to empty it ; there may or may not be desire 
to void it. 

The condition is readily recognized ; the patient or nurse 



236 GENITO-URINARY SURGiCRY AND VENEIREAI. DISEASES. 

will give a history that cannot be mistaken. The bladder 
will be prominent in the hypogastrium, fluctuation will be 
detected. 

Retention, like the disturbances previously described, 
will be due to other causes and is not strictly a 
disease. The causes that are responsible may be stricture 
of the urethra, injuries of the same, prostatic hypertro- 
phy, abscesses in the region, spasm of the muscles, due to 
inflammation, disturbance or reflex irritation, rectal dis- 
eases, etc. 

Paralysis of the nerves of the bladder proper, due to 
brain, spinal or long standing disease of the organ, or to 
one of the fevers. Fright, shame and anger may be re- 
sponsible. Attention, devoted in these directions, will 
locate the cause, which should be diligently treated. 

Treatment, in addition, should consist in relieving the 
accumulation at once. If the urethra be obstructed and 
a catheter cannot be made to enter the bladder, a trocar 
may be used above the symphysis. 

The dangers of such a situation are great, as have al- 
ready been mentioned, under stricture and prostate dis- 
ease. 

Suppression of Urine. 

Is that condition in which there is no urine deposited in 
the bladder, on account of the failure of the kidneys to 
separate it from the blood. It is to be differentiated from 
retention, as indicated under that heading. 

The healthy kidney rarely fails to completely quit its 
work. Suppression, then, is almost invariably the result 
of previous disease in the kidneys. The broad term — 
shock — is cited as a cause ; nervous influences, either central 
or otherwise, may cause it. Certain exhaustive diseases 
have been known to produce suppression, exposure to 



SUPPRESSION OF URINE. 



237 



cold and dampness is mentioned as a cause, urethral and 
bladder instrumentation and operation, are frequently the 
cause. 

The symptoms are pronounced: an anxious expression, 
depression, a quick, wiry pulse, fever, dry skin, headache, 
nausea and vomiting at times ; and a catheter in the blad- 
der reveals no urine. 

Very soon the scene changes, uremic intoxication ad- 
vances, the breath and skin impart a urine odor to the 
atmosphere, restlessness, followed by stupor, coma or 
death (with or without convulsions). The treatment 
should be energetic and prompt, for there will often be but 
little time in which to do. Stimulants, hot milk and 
brandy, strychnine, digitalis in small doses, repeated 
often, hot applications and friction over the kidneys, hot 
vapor baths, muriate of pilocarpine (with caution) is often 
of the greatest service. Diuretine, hyoscyamus, etc., and 
a guarded prognosis. 

The table of Fenwick will be of much service. 



I. Abnormal Urination. 



Abnormal 
urination. 



Alterations in the 
volume of the 
stream (size of 
efflux). 



Alterations in the 
continuity of the 
stream (interrup- 
tion of efflux). 

Alterations in the 
direction of the 
stream (the para- 
bola). 



f Sense of obstruction 
developing sud- 
denly. 



Sense of obstruction 
developing gradu--; 
I ally. ' 



f Efflux arrested sud- 
denly. 

I Efflux arrested in- 
L termittently. 

I Stream bifid. 

Stream vertical. 



Gonorrhoea. 

Acute prostatitis. 

Impaction of stone in urethra. 

Congested senile prostate. 

Onanitic prostate. 

Chronic prostatitis. 

Stricture. 

Chronic lesions of spinal cord. 

Stone in the bladder. 

Orificial valves of mucous mem- 
brane. 

Stone in urethra. 

Senile enlargement of prostate. 

Pelvic tumors. 

Stone, clot, pedunculated 
growth, foreign body. 

Spasm. 

Atony, muscular or nervous. 

Muscular enfeeblement of fever 
or old age. 

Stricture, 
Enlarged prostate. 



238 



GENITOURINARY SURGERY AND VENEREAL DISEASES. 



II. Impossible Urination. 



Impossible 
urination 
(no urine 
passed). 



Suppression of ur- 
ine. 



Retention of urine. 



Non-obstructive. 



I Obstructive, 
f Peritonitis. 
Fevers. 



Renal disease. 

Shock. 

Septicity. 

Hysteria. 

Reflex causes. 

Injury to one kidney. 
—Ureteral obstruction. 
r Rectal collections. 
J Pelvic growths; hydatids. 



Pressure on bladder 1 Soft malignant prostatic 



neck. 

Urethral obstruc- 
tion. 

Reflex spasmodic 
action. 

Nerve lesions. 



I growths. 

Acute prostatitis. 

Congested stricture. 

Impacted stone in children. 

Ruptured urethra, 
f Anal and hernial operations. 
1 etc. 

r Acute myelitis. 
l Tabes. 



III. Uncontrollable Urination. 



f Irrepress- f Inflammatory, 
ibleurina-^ Cystospastic reflex, 
tion. (chorea (?). 

True incon- 
tinence. 



Uncon- 
trollable 1 
urination. | 



Childhood. 



Involun- 
tary urin- -! 
I ation. 



Adult life 
up to fifty. 



LOld age. 



False incon- 
tinence. 



True incon- 
tinence. 



False incon- 
l tinence. 

True incon- 
tinence. 

False incon- 
tinence. 



Sphincter paresis. 
After perineal lithotomy. 
Nocturnal. 
Dirty habits. 



Reflex condi- 
tions. 



[Worms; polypus 
j of rectum; over- 
■j acid or alkaline 

urine. 
[Phimosis. 
f Operative injury of sphincter. 
Advanced tuberculosis of bladder 

with sphincteric impairment. 
Other forms of sphincteric impair- 
ment. 
Injury or disease of spinal cord and 
brain abolishing sphincter power. 
Nocturnal. 

Ataxia with detrusor paresis. 
Tight stricture. 
I Intoxication. 

f Unsymmetrical enlargement of 
( prostate, 
r Nocturnal. 

< Overflow of an atonic bladder from 
i prostatic obstruction. 



Hsematuria. 

Bloody urine, or blood in the urine, is called hgema- 
turia, as opposed to hsemoglobinuria, which is a solution 
of haemoglobin in the urine. Whether this blood be from 
the posterior urethra, the remote portion of the kidney, 
or from intervening portions of the urinary tract, it is 
called hsematuria. All these parts are subject to disease, 
injury and disturbance ; all have blood supply, hence the 
necessity of this understanding preparatory to investiga- 
tion, seeking the source of such haemorrhage. 



HEMATURIA. 239 

If blood comes from the anterior urethra it will show 
independent of urination. It is, therefore, not consid- 
ered if, from the deep urethra it will come with the first 
urine voided, the last being less colored or clear ; if from 
the neck of the bladder there may be some in the first 
glass, practically none in the second and most in the 
third. If a soft catheter be introduced into the bladder 
and the urine that passes through it is bloody you are as- 
sured that its source is beyond the urethra. If now the 
bladder be gently washed and the second wash shows 
blood, you are to conclude that its source is from the 
bladder ; if the second wash be clear, the bladder may be 
manipulated from the pubes, and should this be clear, you 
are to infer the lesion to be beyond the bladder. 

Palpation of bladder and kidneys is of great service. 
The cystoscope will enable you to plainly see the inside 
of the bladder, through it you can see the turbid or 
bloody urine as it enters this organ. 

Hgematuria, then, is not a disease; no more so than the 
blood that drips from an open wound, but rather a 
symptom. 

Any disease or injury of the urethra, seminal vesicles, 
bladder, ureters and kidneys, also the diseases already 
treated of (stone, tumors, etc.), are capable of expressing 
themselves with blood in the urine, and be the underlying 
cause. 

Congestion of the kidneys, embolism, hydatids, cancer, 
tuberculosis, syphilis, malarial or severe fever, acute neph- 
ritis, filaria, vicarious menstruation, may be responsible ; 
certain drugs may cause it, cantharides, turpentine and 
quinine. 

The treatment will be that of the disease or injury that 
is responsible. If due to renal congestion, counter irrita- 
tions, heat, cold, leeches, etc., tannic and gallic acids are 



240 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

recommended. The salts of iron (especially the muriated 
tincture) often do good, rhatany, acetate of lead, opium, 
ergot and benzoic acid, rest, change of climate, good 
hygiene. 

Pneumaturia. 

This condition is of such rare occurrence, and so obscure 
that the mere mention only will be made. Air or gas in 
the bladder is called pneumaturia. Fermentation, due to 
diabetes or putrefaction, could cause it. A fistulous open- 
ing may admit air. The single representative that the 
writer has observed was due to fistula. 

Normal Constituents of the Urine. 

The materials appearing in normal urine come as a 
result of waste products from the food and drink, together 
with retrograde tissue changes. A perfect and complete 
analysis of the urine develops a great variety of sub- 
stances. To appreciate the abnormal, the product in 
health should be known. To-day, we look more to the 
urine as an evidence of disease and an index to approach- 
ing trouble than at any previous time. The advance in 
this direction has done much to develop scientific medicine. 

The normal constituents of the urine are : water, phos- 
phoric acid, ammonia, urea, creatinin, potassium, uric 
acid, organic matter, sodium, hippuric acid, pigment mat- 
ter, calcium, sulphuric acid, chlorine, magnesium. 

The following arrangement will conveniently and con- 
cisely supply much information bearing upon inspection 
of urine, and will suggest the direction in which to make 
examination : 



EXAMINATION OF THE URINE. 



241 



The amount of 
urine secret- 
ed in 24 hours 
by a healthy - 
adult should ' 
be 40 to 60 
ounces. 



f The quantity is said 
I to be increased 
when upward of 
60 ounces are se- 
creted daily. 



The quantity is said 
to be diminished 
when no more than 
15 to 20 ounces are 
secreted daily, in- 
dicative of 



Excess of fluids, liquid diet 
used, or the use of diu- 
f The increase may be retic remedies, 
temporary, which ^ Diabetes insipidus, 
will indicate Nervous diseases, hysteria 

especially. 
I Hydronephrosis (transient) 
f Diabeies mellitus, with high 
specific gravity. 
Bright's disease in its in- 

cipiency- 
Amyloid degeneration, with 
low specific gravity. 
I Cirrhosis of the kidney. 
I Cardiac hypertrophy. 
I Pyelitis, 
r Acute nephritis. 
I Cyanotic cardiac defect. 
J Acute fevers. 
I Inflammation. 
I Shock or collapse from in- 
l juries. 



Or the increase may 
be permanent, 
which will indicate 



The normal 
color of the 
urine is am- 
ber (not straw 
or lemon), due 
to the pres- 
ence of uro- 
hsematin. 



The reaction of 
normal urine 
freshly pass- 
ed is faintly 
acid, due to 
acid phos- 
phate of soda; 
it turns blue 
litmus paper 
red. 

It becomes al-^ 
kaline after 
standing, by 
the produc- 
tion of am- 
monia from 
the urea, and 
turns red lit- 
mus paper 
blue. 



f A pale color indi- 
cates 



A high color indi- 
cates 



II. 

Diabetes insipidus. 
Hysteria. 
Polyuria. 
Hydronephrosis. 
I^arge quantities of fluids taken. 
Diuretics. 
Dark yellow to 
brown red. 



Milky or smoky. 



Orange. 



Red to brownish 
black. 



III. 



Acute febrile diseases. 

Jaundice, from obstruction. 

Chyluria. 

Purulent disease of the uri- 
nary organs. 

The use of santonin, rhu- 
barb or chrysophanic acid . 

Hemorrhage. 

Methaemoglobinuria. 

Carbolic acid poisoning. 

Cancer of the kidney. 



When it is highly 
acid it indicates 



When it is alkaline 
it indicates 



f Rheumatism, acute or chronic. 

I Gout. 

i Oxaluria. 

I Increase of acids in the diet. 

I Fasting. 

iThe use of mineral or benzoic acid. 

f Diseases or injuries of the 

I brain or spinal cord, 
frf m^ oivon ;= fl^«/i " is examined immediately 

J after a hearty meal. 

I The use of alkaline mineral 
waters. 

I The use of the salts of sodi- 

l um, lithium or potassium. 

f Cystitis. 

I Paralysis of the bladder or 
tile (due to am-^ spinal disease, 
monia formation). I Residual urine (stricture or 

L urethral obstruction). 



If the alkali is fixed 
(due to excess of- 
phosphates). 



If the alkali is vola- 



IV. 

"ily'ls'^'above YS"2 ^ Concentration of the urine, 
iiy IS EDove i.u.4 ^ ^^^^ ^^^^ produces excess of urinary 
salts. 

disease. 



The specific 
gravity of nor- 
mal urine 
ranges be- 
tween 1.018 
and 1.022; its 
weight is de- | 
terminedby a I •<.„ , ^ k^i^^ i nnj 



and the urine of 
high color it indi- 
cates 



If the specific grav- 



Acute stage of Bright 

If the urine be ofj 
high color. 



If the 
pale color. 



The use of diuretics. 

1 Hsematuria. 

f Excess of fluids. 
„^,-«^ i^« ^f I Albuminuria, 
urine be of ^ Hydronephrosis. 

I Diabetes insipidus. 

[Nervous diseases. 



242 



GENITO-URINARY SURGERY AND VENEREAL DISEASES. 



Urine may de- 
posit a sedi- 
ment that 
may be either 
amorphous or 
crystalline. 



Amorphous de- 
posits. 



Crystalline de- 
posits. 



Pearly white, which are dissolved by heat, indi- 
cate urate of ammonia. 

Reddish brown, which are dissolved by heat, indi- 
cate urate of soda. 
- White and feathery, made gelatinous by the addi- 
tion of liquor potassa, indicate pus. 

Cloudy white, made clear and fluid by the addition 
of liquor potassa, indicate mucus. 

Dark red or smoky deposits indicate blood. 

White or pearl color, soluble in acids, indicate 
earthy phosphates. 

White or pearl color, soluble only in hydrochloric 
acid, indicate oxalate of lime. 

Pink or reddish-brown color, soluble in acids, in- 
dicate uric acid. 

White or pearl color, soluble in liquor ammonia, 
indicate cystine. 



The odor of 
normal urine 



If it has a sweet odor. 



Glycosuria or diabetes mellitus may be 

Suspected. 
The administration or use of turpentine 

may be suspected. 



If it has a violet odor. 

is character-! If it has an offensive, putrid f Cystitis or decomposition may be sus- 

istic. I odor. \ pected. 

I Certain vegetables and drugs f Asparagus, onions, cauliflower, copaiba, 
L impart characteristic odors. ( cubebs, santal oil, etc. 



In every-day practice, and in the conduct of examina- 
tions for life insurance, public service, etc., the chemic 
and microscopic examination of the urine is made com- 
pulsory. Such work is remunerative, interesting and 
comparatively easy. For all ordinary purposes a cabinet 
like Fig. 82 will afford the necessary apparatus. In the 
absence of this the following will answer: 



One urinometer and cup. 

Two small funnels. 

Red and blue litmus paper. 

Filter paper. 

One dozen test tubes, rack and 
holder. 

One spirit lamp. 

Two graduated glasses. 

Centrifuge, capable of 2,000 revo- 
lutions per minute. 

One microscope, with one inch and 
one -fourth inch objective, slides, 
etc. 



Two ounces e. p. nitric acid. 
Two ounces c. p. sulphuric acid. 
Two ounces c. p. liquor potassa. 
Two ounces aqua ammonia. 
Two ounces Fehling's solution. 
Two ounces sol. chloride of 

barium. 
Two ounces tr. guiacum. 
Two ounces sol. nitrate of silver. 
Four ounces peroxide of hydrogen. 



Urine selected for examination should be taken from a 
collection of twenty-four hours' product; for the same 



EXAMINATION OF THE URINE. 



243 



individual will pass at different intervals during the day 
urine that differs in reaction, specific gravity and color. 
When this is not convenient or practical, the morning 
urine should be preferred. Should it become necessary to 
postpone the examination, or the urine be sent a long 
distance, three or four grains of salicylic acid may be 
^dded to each four ounces of the specimen to preserve it. 
Such an amount should be had for the several tests. 
Smaller quantities often require greater effort and skill. 

Perfectly healthy urine may show a flocculent cloud near 
the bottom of the specimen, which is usually mucus. 

Fig. 82. 




Cabinet. 



Normal urine, may be turbid when voided, due to the 
presence of phosphates of lime and magnesium, which 
disappear upon the addition of a few drops of nitric or 
acetic acid. 

Normal urine, when cold, may show a turbidity, due to 
the precipitation of the urates of potassium, sodium, 
calcium and magnesium. The application of heat effects 
a solution. 

The normal amount of solids voided with the urine in 
twenty-four hours is 925 to 1,075 grains-, of this 300 to 



244 



GENITO-URINARY SURGERY AND VENEREAL DISEASES. 



600 should be urea. Some order or system should be ob- 
served in urine examinations, that suggested in the last 
table will be found convenient. 

The tests for urates and the phosphates being given, 
pus is next examined for, as follows : Permit the speci- 
men to settle, carefully pour off the clear upper portion 
and reserve the thick ; or what is better, put the specimen 




BLEES-MOORE INSTRUMENT CO. 



Queen & Co.'s New Urine Centrifuge. 
For the immediate sedimentation and examination of freshly voided tirine. 

into a centrifuge, Fig. 83, and throw down the deposit. 
The deposit is put into a test tube, to which add about 
half its volume of liquor potassse and shake well ; the 
action of the alkali upon the fat makes a soap, which is 
thick, viscid and ropy, and will foam or lather with water, 
and behave as soap. Peroxide of hydrogen will produce 
its characteristic reaction if pus is present. 



EXAMINATION OF THE URINE. 245 

Albumen. 

The significance of albumen in the urine demands no 
elaboration here, merely the consideration of a practical 
and trustworthy method of knowing its existence. The 
tests for this substance that are ordinarily made use of are 
faulty and unreliable ; the old heat and nitric acid test has 
very often misled the amateur, for the urine may contain 
vegetable alkaloids, oleoresins and peptones, which will 
afford reactions almost identical with small quantities of 
albumen. 

Objection to the Heller test is had for like reasons (this 
is the test now so generally recommended by insurance 
societies), it has some advantages over the first, however; 
it is made by placing several drachms of urine in a con- 
ical glass which is gently tilted upon its side and pure 
nitric acid is cautiously poured down the lower side of the 
tilted glass and the urine floated upon the acid. The glass 
will now show the two substances in this order, if albu- 
men is present, the line between the acid and the urine 
will be milky, other substances produce a turbidity that 
is difficult to distinguish from small traces of albumen. 

The test that can be most implicitly depended upon, 
even though the albumen exists in the minutest quantity, 
is the ferrocyanide of potassium, conducted in this man- 
ner : Drop twenty to thirty drops of acetic acid into a test 
tube, add to this forty to sixty drops of an aqueous solu- 
tion of ferrocyanide of potassium (one drachm of the salt 
to twenty drachms of water), to this mixture add urine to 
half fill the tube, now close the tube with the thumb, and 
shake gently until the three are mixed and then place the 
same in a good light. Within one-half to two minutes 
there will be a milk-like turbidity; if albumen is present, 
the smallest traces will show. With this test error is im- 



246 GENITO-URINARY SURGERY AND VENKREAI. DISEASES. 

possible, for those substances that produce confusion in 
the old test do not respond in this, in other words if 
turbidity comes it is albumen and nothing else. 

Sugar. 

The presence of sugar in the urine has been too lightly 
considered by many, to-day we believe it to be scarcely 
second in importance to albumen. 

The usual tests for sugar lack much of being ideal, the 
time-honored Fehling's is doubly faulty, first the in- 
stability of the solution itself, and second that it is diffi- 
cult to draw the distinguishing color lines between some 
shades of yellow and the reddish brown due to sugar. 
The Whitney test is an excellent one, but the most satis- 
factory of which I have any knowledge is the Purdy test, 
through this test, not only is the presence of sugar deter- 
mined, but the quantity as well, it is simple, inexpensive 
and reliable. To prepare the solution for this test the fol- 
lowing formula and instructions are produced : 

No. 64. 

IJl. — Sulphate of Copper, c. p gr. xliv. 

Caustic Potash, c. p gr. ccxiv. 

Strong Ammonia, U. S. P. (sp. gr. 0.9) fl.^ix. 

Glycerine, c. p, 5^i' 

Distilled water q.s.ft. §xx. 

Mix the glycerine with four ounces of the water, in 
which dissolve the sulphate of copper with the aid of gen- 
tle heat. Dissolve the caustic potash in four ounces of 
the water and mix the two solutions. When cool add the 
ammonia, and then distilled water to make the whole 
measure twenty ounces. 

The test is made by pouring into a flask or large beaker 
glass precisely ten drachms of the test solution, to this 
add twenty drachms of distilled water and bring to the 
boiling point. With a graduated pipette, or burette, con- 



EXAMINATION OF THE URINE. 



24^ 



taining the urine to be examined, add the urine slowly, 
drop by drop, all the while agitating the boiling solution. 
When the blue color begins to fade, the suspected urine 
is added more slowly still (two to five seconds elapsing 
after each drop) until all the blue color in the solution 
has disappeared, and a transparent solution remains. The 
amount of urine necessary to reduce this solution is now 

Fig. 84. 




BLEES-MOORE INSTRUMENT CO. 



Einhorn's Saccharometer. 



Explanation of Figures on Saccharojietek. 

1, 2, 3, 4, 5, mean cubic centimeters; K per cent., Vz per cent., Yx per cent., 1 per cent., or 
their equivalents 2-8, 4-4, 6-8, 8-8, indicate by the Quantity of gas the percentage of siigar in 
the urine. 

If the gas extends to 2 then the urine contains V2. per cent, of sugar. If the gas extends 
half -way between Yz and Vx (4-8 and 6-8) then the percentage is (4-8 plus 1-8 equals) Yz. 



known by the number of the drops added, and by refer- 
ence to the graduated pipette or burette ; and the number 
of the grains of sugar to each ounce of urine is deter- 
mined by dividing 480, the number of grains in an ounce, 
by the number of the minims of the urine necessary to re- 



248 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

duce ten drachms of the solution (or rather to dissipate 
the blue color) and this by three for precisely one-third 
of a grain of grape-sugar reduces ten drachms of the 
solution. 
Example : 

If it requires 20 minims of urine to reduce ten drachms of the solution 
as above, we have -^¥'^^-3=8 grains of sugar to the ounce of urine. 

The fermentation test is quite reliable. The addition 
of yeast to saccharine urine produces alcohol by liberating 
carbon dioxide gas and other products that lower the 
specific gravity of the urine. Each degree of specific 
gravity lost in this process of fermentation represents 
one grain of sugar to the ounce of urine. To apply this 
test J determine the specific gravity of the urine before 
the addition of the yeast. The urine is now mixed with 
fresh yeast, poured into a loosely corked bottle and 
placed in a warm room for twenty-four hours. The clear 
urine is now poured into the urinometer cup and its 
specific gravity taken and compared with the first. 

Example : 

The specific gravity before fermentation was 1.035 

The specific gravity after fermentation is 1.015 

The number of grains of sugar per ounce is 20 

The Einhorn saccharometer (Fig. 84) is a convenient 
instrument for the estimation of sugar. It is used by 
filling the stem of the instrument with urine, to which 
yeast has been added, placing same for twenty-four hours 
in a warm room; as fermentation progresses the gases 
rise to the top of the stem, displacing the urine down- 
ward into the bowl ; the amount of sugar present is esti- 
mated by the volume of gas generated, which is noted on 
the graduated stem on a line with the upper surface of 
the urine. 



CHAPTEE XII. 

HYDEOCELE — VARICOCELE — H.EMATOCELE — SPERMATOCELE — 

TUMOES OF THE TESTICLE— STONE -ACHE— 

NEUEALaiA OF THE TESTICLE. 

Hydrocele. 

The literal definition of hydrocele is water tnmor. The 
collection of serous fluid between the layers of the tunica 
vaginalis constitutes the condition under consideration. 
This tumor may be congenital or acquired, congenital 
when the communication between the abdomen and this 
cavity is not closed by nature ; and acquired when from 
disturbances of circulation there is secreted this serous 
material beyond the power of absorption. 

The causes resulting in the production of this accumu- 
lation are all forms of inflammation of this region. When 
there is acute inflammation accompanied by hydrocele 
there is no treatment indicated except that for the under- 
lying cause, the hydrocele is expected to disappear upon 
the cessation of same. The form of tumor usually com- 
plained of is distinctly chronic ; it develops slowly as the 
result of friction, irritation or some form of injury. In 
the cachetic, and individuals suffering blood depravity a 
form of dropsy here is common ; within itself it needs no 
treatment beyond palliation. 

The rheumatic, with diseased vessels, suffer from a form 
of hydrocele that in no way is dependent upon inflamma- 
tion of the tunica vaginalis, but to arterial sclerosis, 
hence all operations looking toward the obliteration of 



250 



GENITO-URINARY SURGERY AND VENEREAL, DISEASES. 



the sac will be disappointing. Fig. 85 will afford a very 
correct idea of the relation of the fluid to the tunica 
vaginalis, and Fig. 86 is a picture of an average hydrocele 
tumor. 

Hydrocele may exist so small as scarcely attracts atten- 
tion, or to the extent that the patient finds difficulty in 

Fig. 85. 




Hydrocele. 



1. Testicle. 

2. Hydrocele fluid. 



3. Parietal layer of tunica vaginalis. 

4. Visceral layer of tunica vaginalis. 



supporting the scrotum. Several times I have operated 
when the tumor was the size of a child's head. Hydro- 
cele may appear in the spermatic cord, above the cavity 
of the tunica vaginalis proper, in which situation it is. 
known as hydrocele of the cord. 



HYDROCELE. 



251 



Diagnosis. 

The diagnosis of hydrocele is usually quite easy ; there 
are many conditions, however, that give rise to a tumor 
here and should be considered namely, hernia, epididy- 
mitis, orchitis, cellulitis, malignant tumors, tuberculosis, 



Fig. 86. 




Ordinary Hydrocele Tumor. 



syphilitic disease of the testicle, haematocele, spermato- 
cele and epiplocele. 

It is with hernia that hydrocele should be especially 
contrasted ; the following table will make plain the feat- 
ures in common, and the differences that exist. 



252 



GENITO-URINARY SURGERY AND VENEREAL DISEASES. 



Table of Differential Diagnosis. 



Hydrocele. 

1. Develops slowly. 

2. Begins to form at bottom of 
scrotum and develops upward. 

3. It always fluctuates and feels 
firm. 

4. The percussion note is always 
dull. 

5. Inability to feel the testicle. 

6. Tumor cannot be reduced ex- 
cept it be congenital. 

7. The spermatic cord above the 
tumor is normal. 

8. The shape and size of the tumor 
is constant. 

9. The tumor is translucent. 

10. No impulse with coughing ex- 
cept it be congenital. 



Hernia. 

1. Develops suddenly. 

2. Begins at top of scrotum and 
develops downward. 

3. Rarely fluctuates and feels 
doughy. 

4. Percussion note is resonant. 

5. Can always feel the testicle. 

6. Can be reduced by taxis, ex- 
cept it be incarcerated. 

7. The spermatic cord above is re- 
lated with the gut, and cannot 
always be distinguished. 

8. The shape and size of the tumor 
changes. 

9. The tumor is not translucent. 
10. Impulse with coughing is per- 
ceptible. 



By the observance of the above a diagnosis can be made 
which is readily verified with the puncture of a hypoder- 
mic needle, and the removal of a few drops of the serous 
fluid. What has been said in connection with the various 
diseases of the testicle will readily clear the situation of 
further doubt. 



Treatment. 

The object of treatment is to remove the accumulation 
of fluid and prevent its reappearance. Those forms of 
acute hydrocele, associated with inflammatory diseases of 
the testicle and epididymis, demand only such attention 
as is favorable to the exciting causes. Those fluid accumu- 
lations, the result of organic disease, or rather those drop- 
sical conditions, often require palliative tapping, in addition 
to treatment of the original trouble. Ordinarily hydrocele 
is curable ; it is only in these remote conditions already 
mentioned that it is difficult or impossible to cure. 



HYDROCELE. 253 

In prescribing a treatment for congenital hydrocele it is 
to be remembered that the cavity of the tumor communi- 
cates directly with the abdominal, and great caution is 
urged in making irritating injections into such sacs. 

Often a pad or truss applied to the neck of the sac, and 
worn after the fluid has been returned into the abdominal 
cavity, will cure. At times the canal closes, which is 
known by our inability to reduce the tumor. When this 
condition is met, simple evacuation of the sac is all that is 
necessary. Several times I have opened the sac and in- 
serted antiseptic drainage with good results. The surest 
method is essentially the operation for hernia ; a dissec- 
tion is made, the funiculo-vaginal tunic is separated from 
the spermatic cord and neighboring parts ; this is divided 
above the testicle and made to serve the purpose of a 
tunica vaginalis proper ; the remaining portion of the sac 
is sutured in the opening. In this operation all precaution 
against infection should be taken. Hydrocele that is un- 
complicated may be radically cured in a number of ways. 
The practice of injecting irritants into the cavity of the 
tunica vaginalis after emptying it of its contents is an old 
one. For this purpose a long list of substances have been 
used with more or less satisfaction. The object of such 
treatment is to provide adhesive inflammation in the sac 
that will agglutinate its surface and thereby obliterate the 
cavity. In dealing with hydrocele the surgeon will be im- 
pressed with two facts; the first is, how little is sometimes 
nece-ssary to cure a long-standing hydrocele ; and, second, 
how difficult it sometimes becomes to cure a relatively 
simple hydrocele. In this connection I recall a number of 
cases where a diagnosis had been made and verified with 
the hypodermic syringe and the date of operation fixed, 
the patient returning a few days later much improved and 
declining, for the time, further treatment. A number of 



254 GENITO-URINA.RY SURGERY AND VENEREAI. DISEASES. 

such patients have been cured by this simple operation, 
while, on the other hand, radical measures have failed. 
Tapping with a trocar, puncturing with a bistoury or 
evacuating with an aspirator (while occasionally curative) , 
cannot be depended upon except for temporary relief. 

The radical measures in vogue for cure are injection, 
opening, suturing and packing, the establishment of per- 
manent drainage and the removal of the sac. 

Certainly a very large percentage of cases of hydrocele 
can be cured with injections, and as a routine practice, no 
doubt this is distinctly the most applicable; it is done 
without a knife (this fact alone is an argument in its favor 
with the laity), often with little suffering, practically no 
detention from business and relatively safe. Tr. iodine, 
alcohol, sol. bichloride of mercury, spts. of nitre, fl. ex. 
thuja and carbolic acid are the remedies used. This list 
of remedies (which is incomplete), I think, could be 
shortened, for carbolic acid has demonstrated its su- 
periority over all the rest. I have used tr. of iodine and 
fl. ex. thuja (as prepared by Lloyd Bros.) with success, 
but, all things considered, they are inferior to pure car- 
bolic acid. The technique of injection with this latter is 
as follows: The patient is cleansed and the part shaved; 
upon the anterior and middle aspect of the tumor ; imme- 
diately beneath the skin ten drops of five per cent solu- 
tion of cocaine are distributed (in a perpendicular line an 
inch long) ; at the upper portion of the cocainized area a 
hypodermic needle is inserted into the cavity of the tunica 
vaginalis, where it is held in place (which is known by a 
few drops of fluid escaping). The tumor is now grasped 
from its under portion, making the fluid press tightly 
against the anterior surface. 

Now in the lower cocainized area about one-half inch 
below the hypodermic needle, a small trocar and canula, 



hydroce:i.e. 255 

or aspirating needle is passed just through the tunica 
vaginalis and into the canity (not touching the testicle) 
and the fluid completely removed (it is important that all 
the fluid be disposed of for the reason that the acid when 
applied should be diluted as little as possible.) 

The canula or aspirating needle should now be with- 
drawn and the punctured spot held tightly. The hypo- 
dermic needle already in place is fitted to a syringe hold- 
ing from twenty to sixty minims (according as the sac is 
large or small), of pure carbolic acid, diluted with the 
minimum amount of glycerine to keep it liquid, this is 
now slowly discharged into the hydrocele sac, the needle 
removed and the sac manipulated in a way that will bring 
the acid into contact with its entire inner surface, the two 
punctured points are now dried and touched with col- 
lodion, the scrotum is covered with an antiseptic gauze 
and suspended in a bandage. 

The reaction may be slight or it may run high, it is cus- 
tomary for the side to swell, become hard, congested and 
painful for a few days, after which the s^miptoms grad- 
ually disappear and the cure is effected. 

I think a rather active reaction is to be preferred. Some 
authors claim a percentage of cures by this method little 
less than perfect. I am forced to confess that I have been 
unable to cure with a single operation no more than 76 
per cent. 

The Open Operation. 

This operation in my hands has returned the greatest 
number of successes, and is the one I reccommend when 
the injection has failed or when it is imperative to cure 
the first time. 

The patient is prepared and cocainized as before. The 
anterior aspect of the tumor is made prominent and tense 
by grasping the lower and under portion; an incision 



256 GENITO-URINARY. SURGERY AND VENEREAL DISEASES. 

about two to four inches long is made upon the anterior 
surface down to the tunica vaginalis, a trocar is now in- 
troduced and the fluid withdrawn. The tunica vaginalis 
is opened to the same extent as the skin wound, its 
edges are now drawn out and stitched to the edge of the 
skin with a continuous cat-gut suture. The cavity of the 
tunica vaginalis is packed with iodoform gauze and the 
scrotum dressed and suspended. Following this opera- 
tion there is swelling especially if the patient continues 
upon his feet. The gauze is removed in a few days and 
replaced by a smaller quantity, in this way the cavity of 
the tunica becomes obliterated and the cure established. 

Dissection of the Tunica Vaginalis. 

Having failed to cure by the other operations, or if from 
the history and nature of the case it is believed a more 
radical operation is indicated, the tunica vaginalis may be 
removed, thereby making impossible a recurrence on ac- 
count of any disease or disturbance in this part. This 
operation consists in making the same incision as in the 
open operation except it should extend from the top to the 
bottom of the scrotum, puncturing and incising as before, 
after which the tunica vaginalis is dissected out. I have 
not found it necessary to cut it off close to its attachment 
with the epididymis and testicle, but leave about half an 
inch. The wound is packed lightly with iodoform gauze 
and closed with silk sutures ; all except an opening at the 
dependent angle where the gauze is brought out for drain- 
age. I have often closed the wound completely with the 
best results, but believe it better as routine practice to 
drain for a few days. The after care of the patient will 
consist in keeping him upon his back, the part well sus- 
pended and protected until union is complete and inflam- 
mation abates. 



VARICOCELE. 



257 



Varicocele. 

A varicosecl condition of the pampiniform plexus of 
veins constitutes varicocele. This enlargement may be so 
slight that its recognition may be accidental, or so pro- 
nounced that it becomes a serious inconvenience. 

It occurs almost invariably on the left side, which is 
thus explained: The left testicle hangs lower than the 

Fig. 87. 




An Average Varicocele. 

right, the sigmoid flexure of the colon interferes with cir- 
culation on this side, the left spermatic vein empties into 
the left renal vein at a right angle, while the right empties 
into the ascending vena cava at an acute angle. Again, 
the veins in this situation are poorly supplied with valves, 
they are surrounded only by loose connective tissue, and 



258 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

are poorly supported when compared with veins in other 
situations. Their course is through the inguinal canal, 
which is often very narrow, hence its frequent occurrence 
upon the left side. 

Varicocele is conspicuous during the period of early 
manhood. Quite 80 per cent of the author's cases have 
assigned the starting point of such trouble during the de- 
veloping and ripening period of the sexual make-up. 

It is a condition very prevalent, one adult male from 
every nine to twelve is about the ratio. It is very impor- 
tant as will be subsequently shown. 

Causes. 

There are many things cited as causes for the develop- 
ment of varicocele ; injuries, severe straining, certain dis- 
eases and constipation, and there is no doubt that they 
do act in this direction. 

Basing an opinion on personal observation, I am 
forced to believe that prolonged and ungratified sexual 
desire and the extensive indulgence in those practices that 
such a state favors, is responsible for quite a large per- 
centage of varices of this region. The influence of a 
perverted state of the local genital center invites extensive 
and prolonged congestion, and varicocele is but a natural 
consequence of such an unnatural state. 

The Symptoms. 

Varicocele offers a train of symptoms as vague and in- 
definite as can well be conceived. A tumor, more or less 
distinct, is constant. It is larger when standing, es- 
pecially if the scrotum be handled. Elevation of the hips 
tend to reduce it. To the sense of touch the distended 
and tortuous veins resemble a bunch of earth worms 
(Fig. 88). With a fair and thin skin the veins maybe 



VARICOCELE. 



259 



seen, the mass of vessels is thickest at the bottom of the 
scrotum, and disturbs the nutrition of the testicle in a 
double way. Pain of a neuralgic type is often complained 

Fig. 




Relations of the pampiniform plexus of veins in varicocele. 

1. Spermatic artery. 3. Vas deferens. 

2. Artery of the vas deferens. 4. Varicbsed veins. 

of. This may be referred to the testicle, the spermatic 
cord, the urethra or penis ; oftener, however, the pain or 



260 GENITO-URINARY SURGERY AND VEN^REAI^ DISEASES, 

disturbance cannot be described or located; but a restless, 
uneasy and miserable depression that haunts the sufferer 
beyond measure, or a dull, heavy, dragging sensation may 
be noticed. No doubt much of the trouble associated 
with varicocele is psychic, and largely due to the litera- 
ture of the advertising quack; for the majority of my 
patients have shown unmistakable evidence of having se- 
riously studied this free literature and many times fallen 
victim to their proposals and become hypochondriacs, 
either on account of the disease or the treatment; it 
would be difficult to decide. 

The Treatment. 

To advise a treatment for varicocele, one that will cor- 
rect the real and fancied defects, is a matter that taxes 
one^s resources severely, and I am firmly convinced that 
this subject is one too often underestimated. Text-book 
advice is the guide that most of us are forced to seek dur- 
ing early professional life, and the usual recommendations 
found are worthy of severe condemnation. A young 
man will present himself to you a picture of despair, and, 
in a sense, an object of pity. He will assert his claims 
for professional care, possibly through a perverted imag- 
ination, for very often he will have an exaggerated esti- 
mate of his ill; he will suffer pain, inconvenience and dis- 
tress, and be totally unfit for anything ; which to our mind 
may seem unwarranted. We may not be able to explain 
or understand. We advise such a patient to wear a sus- 
pensory bandage, go about his affairs with a light heart 
and have no further thought of his condition. It is cus- 
tomary also to aim to purge his thoughts of everything 
sexual or evil, simply by telling him not to think of such 
things and then he will be well. 

Such disposal of this class of cases does not dispose of 
their trouble. It is this form of advice, upon the part of the 



VARICOCELE. 261 

medical practitioner, that deepens their troubles, and drives 
them by the thousand into the outstretched arms of the 
merciless quack. Such advice as this if taken, no doubt, 
would benefit the average case, but it is as impossible for 
this advice to be accepted as it is to overturn the order of 
nature, or reverse the law of gravity. 

From some cause at least, the local sexual center is 
brought to a state of undue activity, and there is no real 
reason to believe other than the existing varicocele is 
wholly or in part responsible. 

We may find nothing else, and to advise purity of 
thought in the face of such distress, without first making 
it possible, is conduct quite beyond their power. I am 
not inclined to believe that people complain, suffer or be- 
have unusual without cause, and in the matter of varico- 
cele, when there is a congestion, a mass of enlarged and 
much distorted vessels, there is positive evidence of dis- 
turbed circulation, there is at hand abundant cause for 
the display of symptoms and open field for needed labor. 

From this brief outline of thought, together with its 
practical application, as will soon be mentioned, the 
writer is firm in such conviction. Marriage will often 
benefit such patients, it is true, for on account of proper 
relations relief comes to the disturbed sexual region. 
The use of a close-fitting suspensory bandage is of 
service; sexual and urethral hygiene is of great import- 
ance. 

If the tumor is small, and little or no attention has been 
given it, the case can be prescribed for by directing a sus- 
pensory bandage to be worn constantly, keeping the 
bowels open and the sexual organs at rest. Such condi- 
tions, however, are the exceptions. It is seldom that 
such treatment will meet the wishes of the case; when 
more radical measures become necessary. 



262 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

While we agree that varicocele does not directly shorten 
life, and we do not consider it in a serious sense, yet suf- 
ferers will complain, they will run from one physician to 
another looking for cure, they become unfit physically 
and mentally, to discharge their offices; they go mad^ 
contemplate and destroy themselves. Whether the con- 
dition is responsible or not, the facts stand for themselves 
and plainly point out the duty of the surgeon. 

Many operations for this disease have been proposed ; 
clamps, pressure appliances and injections. There are 
only a few, however, that present claims for favor. Per- 
haps the most popular operation today is the subcutan- 
eous ligation of the vessels. With the patient standing, 
and a long needle with its eye in the point, threaded with a 
substantial silk ligature, the veins are separated from the 
vas deferens and artery, and the scrotum transfixed by 
passing the threaded needle between these structures. 
When the threaded point of the needle passes out on the 
opposite side, the suture is removed from the eye, and the 
needle is withdrawn until its point clears the veins. Now 
the needle is made to pass anterior to the mass of veins 
and out the second punctured point beside the suture. 
The needle is now threaded with the suture and drawn 
out the original puncture, bringing with it the suture. 
A loop is in this way thrown about the mass of veins and 
both ends of the suture are presenting at the first point 
of puncture ; which are now firmly tied with a double^ 
knot, cut short and permitted to enter the scrotal cavity. 
The veins may be ligated in this way at one or more 
points. It is claimed for this method that it can be done 
with little pain and detention from business. No knife, 
no blood and with minimum danger, and there is but 
slight swelling. Several times I have done this operation 
and for many reasons think it good. My objections,. 



VARICOCELE 263 

however, have grown since the adoption of another, which 
I think better. The objection is that this, too, is an 
operation in the dark ; that there are times when it is im- 
possible to separate the veins from the arteries and the 
vas deferens; that the difference in pain, swelling and 
detention from business is no less than the open opera- 
tion, which, in consequence of its being open, enables a 
perfectly correct selection of the vessels ligated. 

The operation that I prefer to all others and the one, 
to my mind, having the fewest objections and the greatest 
advantages, is performed as follows: The parts are 
shaved and cleansed, the patient is placed half recum- 
bent, cocaine is distributed under the skin for about 
two inches, extending from the upper surface of the 
testicle to the external abdominal ring, upon the anterior 
scrotal aspect. The tissues are divided down to the thin 
delicate fascia that envelops the veins (pressure from 
below forces the plexus of veins into the incision). A 
blunt, pointed aneurism needle is armed with a substan- 
tial sterilized silk ligature, and the mass of veins and 
spermatic cord are raised upon it. The vas deferens and 
artery and the spermatic artery are released, leaving only 
the veins; the ligature is held and the needle withdrawn. 
The ligature is now cut in the center, making two ; one is 
adjusted to the veins at the upper angle of the wound 
and securely tied, the other is applied at the lower angle 
of the wound and the veins here tied. Now, if the sper- 
matic cord is too long and the scrotum redundant, I cut 
the bundle of veins one-fourth inch from the two liga- 
tures and remove the excised part. Thread a needle to 
one of the ligatures at upper portion, pass it through the 
stump from left to right ; the other stump is treated the 
same, except the needle is passed through this stump 
from right to left. There will now be the four ends 



264 GENITO-URINARY SURGERY AND VENKREAL DISEASES. 

of the two ligatures, two above and two below ; these are 
tied the right above to the right below, the left above to 
left below, thereby bringing together the two stumps and 
shortening the cord. I then resect the scrotum by mark- 
ing the surface, applying Henry's scrotal clamp (Fig. 89), 
placing sutures, cutting off redundant scrotum with strong 
scissors and closing the wound. 

About once in eight or ten times, resection of the scro- 
tum with shortening of the cord is necessary. Simply 
cutting down to the veins and ligating as above is all that 
is indicated, and when only this is done, I must confess 
that I believe it less dangerous and less painful, more 
scientific and correspondingly more satisfactory than the 

Fig. 89. 




BLEES-MOORE INSTRUMENT CO. 

Henry's Scrotal Clamp. 

subcutaneous ligation. Such a patient should be put 
to bed until the effects of the operation have passed off 
and the parts permit being suspended in a bandage. I 
have often operated in my office and in an hour the pa- 
tient would go home, return in a few days with no pain, 
little swelling and free from the annoyance of the original 
condition. I prefer having such patients in a hospital, 
but believe, with this operation, it is as safe as the subcu- 
taneous method and patients are equally free to care for 
themselves. Again, when the open operation is done, 
you are sure the spermatic cord has not been ligated, an 
accident that I have seen from the subcutaneous opera- 
tion performed by very competent men. 



HEMATOCELE, DERMOID CYSTS, SPERMATOCEI.H. 265 

Hsematocele. 

Is a tumor composed of blood; this may be effusion 
into the scrotal tissues, into the cavity of the tunica vagi- 
nalis or within the tunica albuginea. 

Idiopathically, it is a rare affection ; it is usually the 
result of injury; it might be due to the rupture of a blood 
vessel that is diseased. It. will be recognized by the his- 
tory of the case, the character of the tumor, its appear- 
ance and exploratory puncture. 

The treatment should be free purgation, rest, the 
administration of ergot, iron or tannic acid and the ap- 
plication of cold. 

Should the tumor increase, it may be freely opened, the 
parts washed, bleeding vessels controlled, the wound 
closed, or packed and left open. 

Dermoid Cysts 

Of the testicle are occasionally met, they may be within 
or without the tunica albuginea, they are of slow growth, 
not painful, and are readily removed. Their contents 
may be hair, bone, cheesy matter, or a mixture of the 
three. 

spermatocele. 

From the anatomy of the testicle (Fig. 4, page 21, No. 
25) it is shown that here is found the remains of the duct 
of Miiller. This may undergo a cystic degeneration, be- 
come quite conspicuous and be filled with spermatic 
fluid, or due to some defect in the tunica albuginea the 
spermatic element may find its way into the tunica vagin- 
alis, in either situation spermatocele results. The usual 
sign of tumor will be at hand, the hypodermic syringe 
will enable a diagnosis, there is little pain associated 
with it. 



266 GKNITO-URINARY SURGERY AND VENEREAL DISEASES. 

Treatment will consist in removing the collection and 
injecting carbolic acid, or a free incision is made and the 
wound is packed and permitted to close by granulation . 

Stone=Ache. 

For the want of a better term, I have accustomed my- 
self to make use of the above. By stone-ache is meant 
that highly congested and exquisitely painful state of the 
testicles, epididymes, vasa deferentia, seminal vesicles 
and prostate, that comes as the result of prolonged toying 
with the female without relief. 

The diagnosis is readily made. The treatment should 
be a full dose of bromide potash, hot rectal injection, ice 
to the perineum, elevation of the hips, ten grains of 
phenacetine and paint the testicle with ichthyol and 
guaiacol. 

Neuralgia of the Testicle. 

As its name implies, is a painful affection of the organ. 
I have many times been called to treat such cases and 
found difficulty in locating its cause. The entire genital 
organization should be canvassed in search of the same, 
which may be disease in the testicle, epididymis, or a small 
tumor, or disease of the urethra; malaria may be re- 
sponsible; often a neuralgia of this type has been asso- 
ciated with the disease, which would come and go with 
the fever. When of such origin, quinine, iron and 
arsenic will cure. In two recent cases, due to anaemia, in 
which there were pronounced sexual disturbances, I used 
arsenauro with much satisfaction. Hygiene, good food, 
pure air and exercise will ordinarily effect a cure. Hydro- 
therapy may be used, friction to the spine and electricity. 



CHAPTEE XIII. 

€RYPTORCHIDISM — MONORCHIDISM — SUPERNUMERARY TESTI- 
CLES—INJURIES OF TRE TESTICLES— ATROPHY AND 
HYPERTROPHY OF THE TESTICLES— TUBER- 
CULOSIS— SYPHILIS AND MALIGNANT 
DISEASE OF THE TESTICLES- 
CASTRATION. 

Cryptorchidism 

Is that condition of a male in which the scrotum does not 
•contain a testicle. 

When a male is well developed generally, and this defect 
exists, it is presumed that at some point in the abdomen, 
inguinal canal, or perineum, the testicles have been ar- 
rested and lodged. If the male be an adult and exhibits 
a reasonable development of the penis, sexual desires, with 
ejaculation containing spermatozoa, this is conclusive e\d- 
dence of the existence of these organs. A careful exami- 
nation will usually reveal their presence, which will most 
frequently be in the inguinal canal. The peculiar sicken- 
ing pain when the testicle or cord is pressed is pathogno- 
monic. The glands, on account of their unnatural 
■environment, are frequently undeveloped, or on account 
of pressure are diseased ; in either instance sterility would 
result. It is by no means invariable that cryptorchids are 
afflicted in this way, for I now recall a family, the paternity 
of which was a crypt orchid. 

To test the virility of such a subject, the discharge should 
be examined with a microscope, and upon the presence or 
absence of spermatozoa (Fig. 90) alone can an opinion be 
founded. 



268 



GENITO-URINARY SURGKRY AND VENEREAL DISEASES. 



Much inconvenience and embarrassment may result 
from such defects ; mental worry and neurasthenia often 
make surgical interference imperative. Should epididy- 
mitis, orchitis or other disease develop in the testicle when 
in such unnatural situation, it might lead to serious com- 
plications. 

Fig. 90. 




Spermatozoa. 

There are conditions that can be nicely corrected, when 
the scrotum has developed and the testicle located in the 
inguinal canal, and the cord is normal, the part may be 
opened, the organ brought into place and anchored to the 



CRYPTORCHIDISM, MONORCHIDISM. 269 

bottom of the scrotum. Often the patient cannot bear 
this; the tension on the cord, after bringing the testicle 
down, being such that unbearable pain results and the 
testicle must be liberated. Twice have I been forced to 
allow the organ to retire to its former place in the inguinal 
canal after it had been planted in the scrotum for ten 
days. In both cases, however, the general tone of the 
patient was much improved. Frequently the organ is 
sacrificed and removal is indicated. 

TThen the cord is too short, the epididymis may be 
loosened and teased out. making the vas deferens any de- 
sired length. 

Monorchidism 

Is essentially the same as ci-^^-ptorchidism, except that there 
is one testicle in the scrotum and one absent. In other 
respects the conditions are identical. 

Supernumerary Testicles. 

Possibly there are individuals endowed with more than 

two such organs. The cases which have come to my notice 

(which have not been more than a dozen) were tumors of 

varying size that were mistaken for testicles. In no instance 

have I found such bodies to be of glandular construction. 

Seven times I have operated for such tumors ; five times 

the tumor has been cystic, with straw-colored fluid, and 

attached to the cord; once a sebaceous cyst, and once a 

dermoid cyst. 

Injuries to the Testicles. 

The testicles are subject to a great variety of injuries, 
both legitimate, and injuries from insanity. 

Kicks and bruises, falling astride carriage wheels, and 
hurts by machinery. The organ may be cut, punctured 
or lacerated. 

Very extreme injuries may recover with astonishing 
rapidity and leave but slight evidence. 



270 GENITOURINARY SURGERY AND VENEREAI. DISEASES. 

The recumbent position, elevation of the scrotum, the 
application of cold or heat, regulation of the bowels will 
suffice in all ordinary contusions, while control of hemor- 
rhage, surgical cleanliness, replacement of the parts and 
rest will meet the requirements in ordinary incised, or lac- 
erated wounds. 

The secreting structure of the testicle may prolapse 
through a wound of the tunica albuginea. It should be 
cleansed, returned and the tunica closed with fine silk 
sutures. 

When infection of extensive wounds of this region takes 
place the scrotum may swell, become gangrenous and 
slough, leaving the testicle without proper covering. 
Under these circumstances I have seen nature do excellent 
work; warmth, wet bichloride dressings, absolute rest, 
good food and hygiene are indicated. When free from 
infection, skin from convenient parts may be taken to 
make up the deficiency. 

Atrophy and Hypertrophy of the Testicles. 

Atrophy of the testicles may occur from a number of 
causes. It has been shown that many diseases, inflam- 
matory in character, can bring about such a condition and 
atrophy of these organs should call for a search of the 
underlying cause. I believe syphilis is responsible much 
oftener than is generally believed. Sexual depravity may 
be the cause. 

Hypertrophy of the testicle is natural, when on account 
of the congenital absence of one, or the loss of one through 
disease or injury, it is then the compensatory effort of 
nature. I am not aware of true hypertrophy under other 
conditions. 

The treatment for atrophy is that of the disease so ex- 
pressing itself. There is no indication for treatment in 
hypertrophy. 



TUBERCULOSIS, SYPHILIS AND MALIGNANT DISEASE OF TESTICLES. 271 

Tuberculosis, Syphilis and Malignant Disease of the Testicles. 

When a patient exhibits enlargement of one or both 
testicles and this enlargement is not due to acute disease, 
traumatism, hernia, hydrocele, varicocele, hgematocele, 
etc. ; when the organ itself is enlarged, hard, painful in 
a mild degree and has developed slowly and with few 
symptoms, one of these three conditions may be suspected 
and differentiation often requires much study. Such a 
patient should be examined minutely for syphilis, and 
should any condition or history be developed that points 
to such disease, improvement and possibly a cure can be 
expected 5 from twenty to thirty grains of iodide of potash, 
given three times a day, or Exs. 65 and 66 may be used 
and the progress watched: 

No. 65. No. 66. 

R.— Mercauro ^i :R^.— Hydrarg. biehlor gr. ii 

S. Twelve drops in water Kali, iodid ..§i 

after each meal. Peps. Cordial (P. D. & 

Co.) giv 

M. ft. sol. 

S. A teaspoonful in water 
after each meal. 

If, after several weeks treatment, there is no improve- 
ment, Ex. 65 may be used by increasing the dose to four- 
teen drops. 

In the absence of any evidence of syphilis, a search for 
tuberculosis should be made. If found, and the tumor be 
the only focus of tuberculous infection, its removal should 
be insisted upon. 

In the absence of evidence of tuberculosis and syphilis, 
the presumption is malignant disease, and a search in this 
direction for corroborative evidence should be undertaken. 
An exploratory incision is justifiable ; little or no harm 



272 



GENITO-URINARY SURGERY AND VENEREAI, DISEASES. 



will be done such an organ, and the microscope may then 
show tubercle bacilli or cancer cells. The appended table 
will facilitate recognition of such diseases: 





SYPHILIS OF 
TESTICI.E. 


TUBERCULOSIS 
OF TESTICLE. 


CARCINOMA OF 
TESTICLE. 




Specific history. 
Between the ages of 

20 and 35 years, 

usually. 
Disease attacks the 

body of testicle. 


Often a tubercular 

history. 
Rare after middle 

life. 
Disease attacks the 

epididymis, as a 

rule. 


No history. 

No special time of 
life (middle life 
less than the two 




extremes). 
Disease attacks the 
glandular part of 
organ. 


Phys tea I feat u res , 
size and skape ' 


Smooth and hard. 
Never very large. 
Regular in shape. 


Nodular, hard. 
Rarely very large. 
Irregular shape. 


Hard, with fluctuat- 
ing areas. 

Attains large pro- 
portions. 

Irregular. 


Subjective 


Little pain, even 

from pressure. 
Slow development. 
Rarely breaks down. 
Dragging pain. 


Usually slight pain 
from pressure, at 
times neuralgic. 

Slow development. 

Usually breaks down. 


Slight, or no pain on 
pressure. 

Rather rapid devel- 
opment. 

Breaks down and 
develops fungus. 




Course and 
prognosis " 

I 


Lymphatic glands 
rarely involved. 

Skin of scrotum but 
slightly altered. 

May continue years. 

It is curable. 


Lymphatics may or 
may not become 
inflamed. 

Skin gives way as 
breaking down of 
organ advances. 

Rarely curable. 

May continue years. 


Lymphatic glands 
and neighboring 
parts become in- 
volved. 

Skin and scrotal 
veins undergo 
changes. 

Almost always fatal 
within two years. 



Castration, or the Removal of One or Both Testicles 

Is an operation serviceable many times where it is per- 
mitted once ; it will never grow in favor or become popu- 
lar for reasons peculiar to the gender. It is often impossible 
to gain the consent of the patient to relieve him of pain, 
free him from disease and add years of comfort to his 
life through the removal of a useless testicle. Everything 
else must be tried first, and even when he is told the dis- 
ease is cancer, he will insist upon delay which may be 
fatal. The operation itself is an easy one. I have sev- 
eral times performed it with cocaine anaesthesia. 



CASTRATION. 273 

The parts should be shaven and cleansed surgically, 
an incision beginning slightly below the external ab- 
dominal ring and continued upon the anterior aspect of 
the scrotum to the bottom, dividing everything to the 
tunica vaginalis; bleeding vessels are now caught and 
twisted, the parts sponged and the tunica vaginalis opened 
to the extent of the skin wound; the sperniatic cord is 
now ligated with sterilized silk in two places and divided ; 
the testicle is now detached from the scrotum with the 
fingers or handle of scalpel and removed ; all bleeding is 
controlled, the cavity lightly packed with iodoform gauze, 
leaving the end in the lower angle of the wound. The 
cord is now examined ; if no bleeding is noticed, the liga- 
ture is cut short and the stump released. The wound is 
now closed, leaving the drainage from the bottom which 
is removed in two or three days ; in eight days the sutures 
may be removed and in two weeks the patient may leave 
his bed. Some recommend that the vessels of the cord 
Idc ligated individually, that neuralgia and tetanus may 
be prevented. In experimental work upon rabbits and 
dogs — I have operated a great number of times both 
ways — I have not ligated the cord at all, perhaps a dozen 
or more times, and have never seen a death. 



CHAPTEE XIV. 

PHYSIOLOGY OF ERECTION— IMPOTENCE— STERILITY— MASTUR- 
BATION— NOCTURNAL AND DIURNAL POLLUTIONS— SPER- 
MATORRHGEA— INVERSION AND PERVERSION OF 
THE SEXUAL FANCY— NEURASTHENIA SEX- 
UALIS— SEXUAL IMPULSE— SEXUAL 
INFELICITY — THE METHODS 
OF THE QUACK. 

Physiology of Erection. 

That the subjects to be considered in this chapter 
may be more clearly appreciated, normal erection and 
ejaculation of motile spermatozoa deserve under- 
standing. 

The several components of the male genitalia, as de- 
scribed in the first chapter of this book, are to be re- 
membered. 

The penis in a tranquil state, with its arteries con- 
tracted, receiving no more blood than is necessary for 
its nutrition, and with the spaces of its erectile bodies 
obliterated. ISTow, through a sexual impulse which 
may be developed from the brain centre, through the 
lumbar spinal, or the local centre, or through stimula- 
tion of some of the fibres of the nerves coming from 
the lumbar nerves, called the nervi erigentes. By 
virtue of such stimulation, which may be through the 
sense of sight, smell, sound, touch, or thought; the 
arteries of the parts become relaxed, the muscular fea- 
tures of the cavernous and spongy tissues dilate, thus 
opening their spaces, and, in consequence, more blood 
is received and retained in this member. As this con- 



PHYSIOI.OGY OF KRECTION. 275 

gestion advances, all portions become highly vascnlar 
and warmly nourished, the penis begins to swell in all 
its directions, the urethral glands begin active work 
and produce their own secretions in normal quantities. 
The fibrous fascia of the organ is put upon the stretch 
on account of the pressure from within, the veins are 
in this way compressed, and the outflow of blood re- 
duced. During the while the penis slowly and steadily 
raises itself from a perpendicular to a horizontal posi- 
tion, which is accomplished by the influx of blood, con- 
traction of its suspensory ligament, erector penis and ac- 
celerator urinse, muscles ; erection is further aided by 
the compressor urethrae and the perineal group of 
muscles ; which latter do much toward limiting the re- 
turn of venous blood, and thereby prolonging the stage 
of congestion. The penis now stands fully erect at 
an angle in excess of ninety degrees from its flaccid 
condition. In this rigid state, the arterial impulse is 
distinct (it throbs) , while the stimulation to the deep 
muscles cause a spasmodic jerking, oscillating, upward 
movement. The nrethra will be bathed with mucus, 
Cowpers and the prostatic glands are at work, the 
verumontanum swells, blocking the posterior urethra, 
and sexual desire runs high. The culmination of such 
excitation approaches, all functions of the genitalia are 
duly aroused and ready for that final concert of action. 
It is now that the muscular element of the prostate be- 
gins a series of spasmodic contractions, the com- 
pressor urethrse become relaxed, and the contents of 
the vesiculse seminales are forced down and drawn into 
the bulbous urethra. (Regurgitition backwards into 
the bladder being prevented by the congested veru- 
montanum blocking the posterior canal . ) The urethral 
muscles, reinforced by the action of the perineal 



276 GENITO-URINARY SURGERY AND VENKRKAI. DISEASES. 

group, now act upon the spermatic fluid within the 
canal, sending it onward in successive jets, with force 
sufficient to drive it with effect against the os uteri. 

It will be observed that the spermatic fluid is com- 
posite, being made up of spermatozoa, the secretions 
from the vasa deferentia, vesiculse seminales, prostate, 
cowpers and urethral glands. 

Impotence and Sterility. 

By impotence is understood the inability to perform 
the sexual act. A man, at his maturity and in normal 
health, should copulate, at least twice a week, dis- 
charging something like one-half to two drams of sper- 
matic fluid, and be stronger, mentally and physically, 
on such account. The power is physiologically lost 
about the age of fifty-five years, hence the term impo- 
tence applies to that period of man's life between the 
ages of nineteen and fifty-five years. 

The subject has been conveniently divided into or- 
ganic, atonic and psychical impotence, and under these 
headings all forms of the disease may be considered. 

Organic Impotence. 

Organic impotence exists when there are irregulari- 
ties of the penis, or scrotum, to such an extent that 
intromission is impossible, and those brain and spinal 
affections impairing or abolishing the sexual centres. 
Extreme size of the penis, preventing intromission, 
and those situations where the organ is bound by ad- 
hesions may cause it. The diagnosis and treatment 
will consist in discovering the cause of such failure of 
erectile power, or intromission, and employing proper 
treatment and surgery for the correction. Organic 
impotence is, therefore, a condition very often beyond 
remedy. 



ATONIC IMPOTENCE). 277 

If we accept the definition of sterility in the male as 
inability to procreate offspring, it follows that all suf- 
ferers of impotence are sterile. 

Atonic Impotence. 

To this class belong* all those weakened on account 
of local and general disease, sexual excess and demor- 
alizing practices, as well as those whose sexuals have 
known no rest, due to prolonged and ungratified long- 
ings. With this form of impotence the desire may be 
present or it may be abolished. Erections may be sub- 
stantial, and ejaculation may occur before intromis- 
sion ; or the erections may occur and fade away before 
intromission, or shortly afterward, and no ejaculation 
or copulation be permitted; again, both erection and 
sexual desire may be v/ anting. 

The causes leading to such an end are numerous ; 
in addition to those alluded to, certain drugs are re- 
sponsible, alcohol, tobacco, the use of strychnine and 
atropine as given for the cure olp whisky habit, the 
bromides, opium, lead-poisoning, coffee, etc. 

When erections occur and the desire continues, and 
impotence is due to precipitate ejaculation or to mo- 
mentary erection, the type is called irritative, as 
opposed to paralytic impotence, where the desire is 
wanting and erections do not occur. 

Symptoms. 

The symptoms in this condition are very pronounced, 
and cannot well be mistaken. There is a distinct neu- 
rotic feature in all these cases ; the patient will com- 
plain of a nervous, restless or dead feeling in the sexual 
tract; he will be depressed in spirits, with poor diges- 
tion, will complain of vague pains anywhere from the 



278 GENITO-URINARY SURGERY AND VENEREAI, DISEASES. 

glans penis to his head ; there may be a sensation in 
the urethra reserabhng fluid ; there may be disturbance 
of the urinary function of a nervous kind, failure to 
promptly void urine or inability to retain it ; there is 
often a cold and pale condition of the penis, a slight 
discharge of mucus, a weak heart, shortness of breath, 
an anxious and confiding bearing and a general picture 
of despair. 

Diagnosis. 

From the history of the case an index to the situa- 
tion can be obtained. The general health should be 
carefully noted — the heart, the liver, the lungs, and 
particularly the kidneys (the two-glass test should be 
made). After having attended well to these prelimi- 
naries, it is my custom to now inspect the external 
genitals, palpate the testes, the vasa deferentia, epi- 
didymes ; pinch the thigh and observe the reflex of the 
cremaster muscle and dartos, palpate the urethra, ex- 
amine the prepuce ; now pass the finger up the rectum 
and examine the prostate and the visiculse seminales, 
and determine their tone. ]^ow prepare a bulbous 
bougie with flexible stem, slowly and gently pass it 
down the urethra, carefully noting the condition of 
the parts as they are acted upon b}^ the bulb ; note all 
irregularities, both of the urethral calibre and of its 
sensation ; in this way explore the entire canal and 
let no part of the genital tract escape notice. From 
such an examination all necessary information can be 
had, and without this complete work an opinion would 
not be justified. 

Prognosis. 

The prognosis of this form of impotence is good. I 
think about eighty per cent of all imp o tents belong to 
this division ; about eighty per cent develop this in con- 



ATONIC IMPOTENCE. 279 

sequence of gonorrhoea, ungratified sexual desire and 
masturbation ; in ninety per cent the cause of the 
trouble can be located and the trouble corrected, and 
when we fail to do either, we have made the mistake 
in classifying it under the head of atonic impotence. 

Treatment. 

Atonic impotence requires for its successful treat- 
ment, hygiene (general) and hygiene (sexual) . Bring 
that environment about the patient that best suits his 
general condition. If his trouble is due to stricture, 
either cut or dilate it ; if a long prepuce or a tight 
meatus exists, dispose of them ; if there is urethral in- 
flammation, treat and cure it; if there is prostatic, 
vesicular or bladder inflammation, give necessary at- 
tention; in other words, treat thoroughly and well the 
underlying cause, and have the patient all the while 
deeply impressed with the fact that only one thing can 
come from your efforts, and that is cure. 

A condition that is responsible oftener than all 
others combined is a posterior urethral neurosis, in 
other words, an over-sensitive and tender prostatic 
urethra with more or less congestion in the prostate 
and vesicles ; and those subjective sensations so univer- 
sally complained of by this class of sufferers are readily 
understood when we consider the abundant nerve sup- 
ply of this part of the canal. 

The urine of such patients is frequently worthy of 
strict attention. Very often sugar, albumen, oxalate 
of lime, excess of phosphates can be found. All 
source of irritation should be examined for, and when 
possible, removed. A flssure of the anus, a rectal fis- 
tula and hemorrhoids often play a part in the causation 
and maintainance of this condition. 



280 GENITO-URINARY SURGERY AND VENEREAIv DISEASES. 

The paralytic type, that condition where there is 
absent both desire and erection, suggest brain, spinal 
or other form of organic or wasting disease, and atten- 
tion should be especially searching in these directions ; 
these cases, however, are rare as compared with the 
irritative form, which latter are almost invariably due to 
local disease or disturbance. 

Tonics, electricity, cold sound, change of climate 
and a sea voyage are the indications for treatment in 
the paralytic variety. 

Rxs. N'os. 67, 68, 69, 70 may be used with benefit. 

No. 67. No. 68. 
R. — Stryeh. sul gr. ii R. — Arsenauro ^i 

V *- A ^- "Z ^-'^^ S. Ten drops in water 

Ext. damianse 3iss ^^.^^ ^^^^^ ^ 

M. ft. pil. No. LX. 

S. One pill after each meal. 



after meals. 



No. 69. No. 70. 

R.— Fl. Ex. Nucisvom "j R.— Fl. Ex. Saw. palmetto ^ii 

Fl. Ex. Sanguinariee, ! ^.. Fl. Ex. Ignitia amara 3^ 

Fl. Ex. Cinchonge [ ^^ ->" Fl. Ex. Coca ^i 

Fl. Ex. Matricarise .... J Fl. Ex. Cascara ar §i 

]!^_ Elix. Cinehon §ii 

S. Fifteen drops in water ^• 

after meals. S. A teaspoonful in water 

after each meal. 

In dealing with the irritative, the patient will re- 
ceive much benefit through the use of the cold sound, 
cold antiseptic irrigations, deep injections of nit. of 
silver (five to ten grains to the ounce) , one or two 
drops of such a solution applied to a nervous or sensa- 
tive spot every five to eight days, strong solutions 
of tannic acid may be used in this way, copper 
sulph., five to ten grains to the ounce, thallin sulph., 
ten grains to the ounce, argonin, ten grains to the 
ounce, zinc sulpho carbol at, thirty grains to the ounce, 
boro-glyceride, all may be used with more or less sat- 
isfaction. 



ATONIC impotence;. 



281 



Counter irritants to the perineum; hot and cold 
rectal injections ; weak galvanism, the negative pole 
to the urethra, the positive over the lumbar spine ; 
Faradism may be used in the perineum and over the 
external genitals and spine ; cold plunge baths, fol- 
lowed by brisk friction. 

The psychrophor (Fig. 91) may be used for apply- 

FiG. 91. 




BLEES-MOORE INSTRUMENT CO. 



Psychrophor. 

ing heat or cold in the urethra ; it is a most useful in- 
strument in the treatment of atonic impotence ; it may 
be used every third day. I have used it with wonder- 
ful effect by first passing cold water through it, thor- 
oughly chilling the nerves of the urethra, then attach 
a fountain of water raised to about 115 degrees F. and 
again changing to the cold ; each sitting should last 
about eight minutes. 

Rxs. ISTos. 71 and 72 may be found serviceable in 
quieting the sexual organs and inducing repose, for 
these organs bear rest remarkably well, and even if 
there be no erection and no desire it does not follow 
that. wasting or degeneration is in progress. 



No. 71. 

R. — Hyoscine gr. ss 

Fl. ex. Humuli Ji 

Tr. vallrianee gi 

Spts. menth. pip §ss 

Tr. cardam. eo giiiss 

M. 

S. A teaspoonful in water 
four times in twenty -four 
hours. 



No. 72. 

51:.— Sodii. brom gi 

Liq. potass, arson '^ss 

Tr. cardam. co ") i^. 

Aqua pur jaa^iss 

M. ft. sol. 

S. A teaspoonful in water 
four times daily. 



282 ge;nito-urinary surgery and venkreaIv diseases. 

After local and general treatment has been carried 
on to a successful degree, and there can be noticed 
nothing in the case except the lack of desire or fear 
that a cure is not complete, or more properly, a lack of 
confidence on the part of the patient. Malt Nutrine, 
as prepared by The Anheuser-Busch Co., is an excel- 
lent tonic and stimulant. Gudes' ferro pepto man- 
gan. is an ideal iron tonic. Elix. iron, quinine and 
strych., Phospho-Albumen Co., may be of great ad- 
vantage. Ligation of the dorsal vein of the penis has 
been wonderfully successful. 

Psychical Impotence. 

In this trouble the fault is in the head — it may be 
purely an imaginary state. The genitals may be per- 
fect, the patient a moral and correct man, with no his- 
tory of previous venereal disease, and one who has 
never gone to excess in any direction, and from all ob- 
tainable evidence he may be a perfect man. He may 
have great sexual desire with feeble erections, or he 
may have desire with erections that are normal, but 
cannot command them at proj^er times ; he may have 
desire and vigorous erections when in the presence of 
certain characters and a feeling of disgust for others. 
Usually such a patient will long for and lust after 
those with whom sexual relations are impossible, 
and have no desire whatever for others. Copu- 
lation may be possible with clothing on and erec- 
tions may fail when undressed. As erections take 
place a sense of shame, fear or pity may develop and 
the erection be lost. Over-anxiety for sexual relations 
may prevent satisfactory erection, this is often noticed 
with the newly married ; ardent love, admiration and 
respect for the new wife may result in temporary 
psychical impotence. 



PSYCHICAI. IMPOTENCE. - 283 

Young men who have by chance learned of the evil 
incident to masturbation and the disaster following 
nocturnal pollutions through the literature of the 
quack, educate themselves to believe their manhood 
lost, and with great hesitation and remorse lay their 
fancied troubles before the surgeon. The influence of 
alcohol, certain dispositions, occupations and sur- 
roundings may develop this form of impotence, the 
prognosis of which is good. 

Treatment. 

An examination and investigation of the patient 
should be made as suggested in the atonic variety, that 
you maybe sure the case is one of psychical impotence. 
This prolonged and searching examination is doubly 
necessary ; first, that no error in classification of his 
trouble maybe committed; and, second, that the pa- 
tient may be profoundly impressed with the skill, 
familiarity and earnestness of his attendant. With 
such an impression formed, the cure is half established, 
for the patient is now in proper form to receive sug- 
gestions ; you have his confidence and respect, he will 
improve at your will. When such a patient has been 
in the hands of others it is well to be reserved, say but 
little, and from his story learn his disposition and the 
methods that were adopted by his former physician, 
for on no account should such measures be prescribed. 
Do not say, by word or act, that his previous treatment 
was improper, about this say as little as possible. As- 
sure him in most positive terms that you are compe- 
tent to cure him, remember well your advice to him 
and never recede from a position when taken. If cold 
sounds were used before, you are to use them warm, 
or none at all. If electricity has been used, you are 



284 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

to apply massage ; in other words, do that in which he 
has not lost confidence. If he has desires and no erec- 
tions, endeavor to strip him of his desires by the use 
of bromides, camphor, hyocyamine and suggestion. 
If he has erections, subdue them ; if he suffers noctur- 
nal emissions, limit them, and convince him that no 
harm will come to him from that source. Build him 
up generally, improve him morally and sexually, have 
him do the things he least cares to do and leave off 
the things he would do ; in other words, impress him. 
If he is a married man, and has lost desires for his 
wife, but has desires for others, you may convince him 
he is mistaken. If he has been bearing sexual rela- 
tions once or twice a week, but has failed for some 
weeks to have erection and desire, you may stimulate 
him, feed him, and enjoin continence upon him; 
advise him of the necessity of not having desires or 
erections for a month, of not attempting sexual rela- 
tions, and he is sure to violate such trust and do him- 
self a great good. A wife or mistress can do much to 
break the spell of such a sufferer. I have frequently 
advised them to appear attractive and girlish, re- 
pulse his solicitations ; fight him off ; run away from 
him, and practically force him to overpower her. En- 
couragement and artifice, the local use of cold sounds, 
the psychrophor, electricity, cold baths, friction, 
horseback riding, the bicycle, the most nutritious diet, 
a visit where there are no women, possibly a little sur- 
gery ; enlarge the meatus, or remove the prepuce. The 
use of such remedies as damiana, nux vomica, gold, 
phosphide of zinc, ergot, cantharides (in doses of one 
drop of the tincture), will return his manhood. 



STERIIvITY, MASTURBATION. 285 

Sterility. 

As previously defined, sterility is that state in which 
an individual is incapable of procreating offspring. It 
has been learned that impotence carries with it sterility ; 
a sterile state, however, does not mean impotence. A 
sterile man may be fully potent; he may copulate, dis- 
charge seminal fluid and receive all the pleasure and 
satisfaction that his nature wishes ; in fact, many men 
are sterile and .not aware of it. 

I have a patient upon whom double custration was 
performed at the age of thirty, who is potent. Sterility 
may be due to absence of, or inability to discharge, 
spermatic fluid, or to the absence of motile spermatozoa 
in the discharge. All those conditions, occluding the 
spermatic canal, from the ejaculatory ducts to the con- 
voluted tube in the globus major of the epididymis may 
be responsible. In this way double epididymitis, in- 
flammation in the vasa deferentia, caustic injections, 
stone, and surgery in the prostatic urethra, those dis- 
eases and injuries destroying the secreting function of 
the testes, castration, certain diseases acting upon the 
blood, syphilis, tuberculosis, etc., may be the under- 
lying cause. 

Treatment 

Is that general tonic course calculated to restore the 
secreting power of the testes w^hen the fault is of such 
Sj character, and the employment of such surgery that 
the occluded canal may be restored, if the condition 
will admit; all other cases are beyond the reach of 
our art. 

Masturbation. 

Masturbation (solitary vice or practice, and self- 
abuse) refers to the demoralizing custom of the indue- 



286 GENITO-URINARY SURGERY AND VENEREAIv DISEASES. 

tion of veneral orgasm upon one's self. This is usually 
accomplished in the human male with the hand, and 
quite good authority add this to the definition of the 
practice. I protest, for the reason that most animals 
masturbate ; I have seen dogs, horses, monkeys, sheep 
and chickens. I am reliably informed by the keeper 
of a menagerie that goats, bear, rabbits, lions and most 
animals practice it. I can recall a number of patients 
who could masturbate wath the mind, the motion of a 
rocking chair, the friction from horseback riding and 
the motion of a cart; the hand not being engaged. I 
believe then that masturbation is the production of 
venereal orgasm through mental copulation, with or 
without friction. Often the memory of the confirmed 
masturbator is poor ; he cannot tell if a mental picture 
is cohabited with or not, but all others who have 
practiced it will admit that the mind is fixed upon such 
a scene, and sexual relations are held with such mental 
image. 

The practice of masturbation among boys is so uni- 
versal that it is the exception to find one at the age of 
fifteen who has not been dubbed and admitted to thi& 
chamber of veiled folly by his senior schoolmates and 
associates. 

The practice does not always end with boyhood ; it 
is occasionally continued throughout the active life of 
man. Girls are not given to such habit, as a rule, for 
reasons too lengthy to appear here. 

The evils of masturbation are many, the practice is 
not as disastrous as some believe, and far worse than 
many teach. It is not an error that deepens nor is it 
one difiicult to cast aside. I believe that ninety-eight 
per cent of boys so indulge themselves and only twelve 
per cent of men continue it after their maturity. It can 



MASTURBATION. 287 

be said of masturbation that it is a dispoiler of sexual 
tone and refined morality ; it is a disgusting, cowardly 
and unmanly habit (not disease) ; it is the outgrowth 
of corrupt association, literature and environment, 
largely due to inattention on the part of the parent. 
That the long train of infirmities and ills ascribed to its 
frequent and excessive indulgence, in a strict physical 
sense is little less important than sexual intercourse 
practiced to the same extent. That it is more ruinous, 
is due to the mental effort in producing and holding a 
seductive image in the mind for the accomplishment 
of such imaginary intercourse, and the reflections, 
forebodings and depression that possess the subject 
through the sense and knowledge of committing a 
wrong and inflicting injury upon himself, with a full 
and exaggerated idea of consequences. That mastur- 
bation is practiced oftener than copulation and is cor- 
respondingly more depressing is not because it is 
preferred to the latter, but for the reasons that opportu- 
nities for the solitary practice are created at will, con- 
sent of a female, suitable place, etc., is not necessary; 
again, masturbation does not require an erection; the 
penis may be flaccid at first and become erect, or it may 
remain flaccid throughout the entire performance of 
self-abuse, as opposed to sexual contact, which demands 
a substantial erection. 

The congestion of the genitals incident to normal 
copulation, and that state following its completion, is 
distinctly different from those conditions when mas- 
turbation is resorted to ; the same may be said of that 
acme of joy coming with the explosion of nerve force 
that terminates the act. Masturbators do not receive 
the rest, satisfaction and repose of the genitals, nor do 
they get that natural enjoyment. It is the nerve ex- 



288 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

plosion followed by that state of momentary anaesthesia 
as well as the real loss of spermatic fluid that taxes the 
mental and physical strength. 

Symptoms. 

The mastiirbator, if a child or youth, will show evi- 
dence of exhaustion, will be nervous and restless, will 
be pale, dyspeptic and show an anxious and unnatural 
face expression. 

If a young man, he will be dull at school, inattentive 
to his duties, anemic and nervous ; he will shun society, 
be timid, bashful and forgetful ; will take no interest 
in manly or boyish sports ; will be melancholy and 
cowardly ; he will have a weak heart, poor circulation, 
cold and moist extremities ; and his genitals will look 
tired; he will have a subdued face expression. 

If a man, he will be indifferent and incompetent; he 
will lack strength of character and manly stability ; he 
will be ill-tempered, unreasonable, selfish, narrow, 
hypochondriacal, with the instincts of a cur. 

Treatment. 

The prevention of such a habit is a matter that de- 
serves more general recognition, and this should come 
from father to son ; it should be no less the aim of a 
parent to promote a robust constitution, protect, de- 
velop and mature a normal sexual organization in their 
sons than to engage themselves in their behalf in other 
directions. In fact, I think the greatest gift to a young 
man is in this direction. I quite appreciate the great 
disadvantage under which a parent must labor and 
know how blind we are to the imperfections of our own 
household; yet if a boy be guarded by vigilant parents, 
from the dropping of his swaddling clothes on to the 



MASTURBATION. 289 

attainment of his maturity, if during this while the 
father interests himself in his son, makes a companion 
of him, supervises his association, recreation, hterature 
and pleasure, puts before him the beauties of normal 
and manly habits, this pernicious practice would find 
fewer victims. 

When the patient is believed to be given to such a 
fault, it is best that the father secure the confidence of 
such a son ; do not force him to lie and conceal his 
weakness by asking him if he masturbates, but rather 
announce to him in a positive way your knowledge of 
his conduct, when he Avill either confess or become so 
confused that Avill bear out the presumption. 

A long prepuce often attracts attention to the part, 
and masturbation is the result ; when such exists cir- 
cumcision is indicated. 

Idleness, stimulants, indoor life, should be avoided. 
I know of nothing so wholesome for a masturbating 
young man as work upon a farm— labor that taxes the 
physical strength and spares the mental. A young 
man fresh from school, with sunken eyes, pallid cheeks, 
nervous and dyspeptic, if made to follow a plow six 
days in the week, for eight hours a day, will very soon 
lose all inclination for such indulgence. 

It is not well to terrify a boy with exaggerated 
stories, or undertake to force him, by harsh means, to 
abandon his habit ; most people may be induced, and 
led by reason, but refuse to be forced or driven, and 
the masturbator is no exception. 

The following prescriptions may be used as tonics : 

No. 73. No. 74. 

R- — Elix. valerinate ammon ...^iv ^. — Pil. ferr. quin. et. zinei, va- 

S. A teaspoonf ul in water lerinate. 

four times a day. (Schieffelin's) No. L. 

S. One after each meal. 



290 GENITO-URINARY SURGERY AND VENEREAIv DISEASES. 

No. 75. No. 76. 

R.-Strych. nitrat Ua^r ss R.— Ammon. brom \^^ ^.. 

Atropine sul P^ ^^' ^^ Sodii. brom /^^ 3" 

Ext. gentianse gr, c Elix. peps. bis. et. strych..§iv 

M. ft. pil. No. L. M. ft. sol. 

S. One after each meal. S. A teaspoonful in water 

after meals. 

Nocturnal and Diurnal Pollutions 

mean, respectively, the involuntary escape or loss of 
seminal fluid during sleep, or while awake. 

I*»^octurnal emissions, attended by pleasurable dreams, 
occurring not oftener than twice a week with the robust 
and continent, are not considered a menace to health, 
except the individual takes notice of it, thinks, 
worries, and becomes hypochondriacal, or suffers real 
weakness and depression. It is when the emissions 
take place oftener, and when there is evidence of ex- 
haustion, that such pollutions require notice. The weak 
and nervous, the overworked and the sensitive, com- 
plain most. 

"When the sexual organs have become accustomed to 
exercise, either through normal coition or through mas- 
turbation, and such relations or practice be discon- 
tinued, nocturnal emissions afford the most natural 
relief, and are to be expected. The masturbator will 
have such discharges more readily than one accustomed 
to sexual contact ; his deep urethra is in a state of con- 
gestion, the nerves of sexual excitability on the alert, 
there is hypersesthesia of this region and the slightest 
stimulation will occasion emissions ; a full bladder, con- 
stipated bowels or filled seminal vesicles will evoke 
them. Kectal irritation, bladder, spinal, prostatic or 
any disease or injury disturbing the circulation of the 
genitals, will have such effect. 

The involuntary passage of semen during the day in 
the form of pollutions is a condition quite rare. Very 



NOCTURNAL AND DIURNAL POLLUTIONS, SPERMATORRHCEA. 291 

excitable characters often have discharges of seminal 
fluid while fondling a female ; such emissions, however, 
are noticed, and are therefore not involuntary. I have 
seen two patients afflicted in this way with whom the 
pollutions occurred without their knowledge. When 
such a condition as this exists, serious brain or spinal 
disease should be suspected. 

Treatment. 
The treatment for involuntary seminal losses should 
consist in making peace with the sexual apparatus ; 
sexual and urethral hygiene rigidly observed will in 
most instances meet the indications. Physical outdoor 
work is excellent, cold douches, electricity to the spine, 
a hard bed with light covering, emptying the bladder 
several times during the night, the removal of all 
sources of irritation, a light dinner, and that tonic 
course necessary to strengthen the nervous and phy- 
sical powers. Especial emphasis is placed upon the 
avoidance of scenes, association and literature calcu- 
lated to stir the sexual. When the deep urethra is 
sensitive (as is frequently the case) it may be treated 
to tannic acid dissolved in glycerine and applied with 
deep urethral syringe, or silver nitrate, copper sulphate, 
ichthyol, etc., as recommended in posterior urethral 
neuroses. To quiet the sexual centers, prescriptions 
78, 74, 75 and 76 may be used. 

spermatorrhoea. 

Spermatorrhoea is a condition in which there is grad- 
ual loss of spermatic fluid without erotic sensation. 
The existence of this condition is discredited by many 
observers. Whether spermatorrhoea, as we accept it, 
be a distinct disease or a symptom of some other 
pathologic state, there is no doubt that such a leakage 
of material bearing spermatozoa is occasionally met. 



292 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

Spermatorrhoea is quite rare and is of tener associated 
with other diseased areas than otherwise, yet I have 
seen many cases in whose urine could invariably be 
found spermatozoa, and nothing additional could be 
demonstrated. Young men of gullible inclination, 
anxious and apprehensive, whose genitals have been 
abused through masturbation and leveling association, 
apply to the surgeon for relief of what they believe to 
be spermatorrhoea. They will complain of suffering 
every weakness of mind and body ; they will ascribe 
their extreme hopeless condition to a discharge that 
proves to be merely that normal mucus that bathes the 
urethra during erection. Most often the only visible 
discharge will be that glued condition of the meatus 
found upon awakening after the subsidence of a vigor- 
ous erection, and there may not be a spermatozoid lost. 

The advertising specialist falls heir to this class of 
patients, and almost invariably they have gone the 
rounds before they find their way into reputable hands. 
From my records I select the first 100 cases coming to 
me for relief for what they believed to be spermator- 
rhoea, and present the following : 



Ninety-one out of 100 had received treatment. 

Sixty-nine out of 100 had received quack treatment. 

Fourteen out of 100 had taken patent medicines or druggists' pre- 
scriptions. 

Eight out of 100 had received treatment from regular surgeons. 

Eighty- seven out of 100 had received quack literature. 

One hundred out of 100 confessed to having masturbated. 

Forty-two out of 100 had gonorrhoea once or oft^ner. 

Five out of 100 had syphilis. 

Sixty out of 100 had marked hypersesthesia of the deep urethra. 

Twenty- eight out of 100 had perceptible hypersesthesia of the deep 
urethra. 

Nineteen out of 100 had a stricture of the urethra. 

Ninety- seven out of 100, no spermatozoa were found in the discharge 
or urine. 



SPERMATORRHCEA. 293 

Three out of 100, spermatozoa were found in the discharge and urine. 

Seventy -four out of 100 were between the ages of fifteen and twenty 
years. 

Eighteen out of 100 were between the ages of twenty and twenty-five 
years. 

Three out of 100 were between the ages of twenty and thirty years. 

Two out of 100 were between the ages of thirty and thirty-five years. 

One out of 100 was forty-two years of age. 

Two out of 100 were above forty-two years of age. 

Diagnosis and Treatment. 

[N^ever sympathize with a young man who humbly 
applies for relief of such a fancied ill. He will be de- 
pressed, demoralized and abused ; most often he will 
have but a single dollar, a poor income and is in every 
sense worthy of encouragement (not sympathy) . Per- 
haps the first question he will ask, ''Do you charge for 
consultation?" This question, together with his sub- 
dued bearing, tells his story. You may be reasonably 
sure that the picture of lost manhood, made hideous 
with a background of mental and physical decay, has 
been put before him. That it is this recollection from 
which he cannot flee or throw aside that hovers over 
and haunts him day and night. It is this masterpiece 
of the artful quack that robs the young men of their 
individuality and manhood. It is this literature that 
poisons their reason, directs their attention to parts 
that require no thought, drives them to a state of ex- 
treme misery and disappointment, and totally unfits 
them for business or pleasure. 

If the United States would deny the use of the 
postal service to these knaves, the daily press be made 
responsible for the injury done by their advertisers, and 
the several states be made to exercise a guardianship 
over her subjects, spermatorrhoea, in its common ac- 
ceptance, and the wretchedness of a large army of 
young men, would be unknown. 



294 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

The influence of the mind is most powerful, and it is 
necessary that the thoughts be turned in a different 
direction. Encourage these young men, give them 
such work and such directions for treatment that their 
minds may be fully engaged. 

Their urethral neuroses are often dependent upon 
their general nervous state, and as this improves so 
do the others. The over-secretion is often due to this 
state of mind and the excited parts ; quiet the one and 
the other will stop. Search diligently for an underly- 
ing cause, and when found, apply proper treatment 
— a stricture, long prepuce, varicocele, hydrocele, ure- 
thral ulcer, diseased seminal vesicle, may be at fault; 
nothing should be overlooked. 

Inversion and Perversion of the Sexual Fancy. 

Disgusting as such matters are, yet it is impera- 
tive that the genito -urinary laborer be awake to this 
sad and pitiable state of the sexuality of his fellow- 
beings, for it is often his province to learn of the ex- 
istence of this depravity at a time when much good 
can be done. 

Satyriasis 

Is that condition- of the male in which there is insati- 
able and ungovernable desire for copulation, with full 
erectile power, and without apparent exhaustion or 
weakness resulting from excessive indulgence. With 
such subjects this desire is so prominent and strong 
that every thought and wish is bent toward the grati- 
fication of the sexual. Two types of this defect exist 
— the paroxysmal and the constant. 

Nymptiomania 

Is the extreme sexual longing in the female, and is 
essentially the same as satyriasis. In both of these 



NYMPHOMANIA, SADISM, MASOCHISM, HOMOSEXUALITY. 295 

there is usually lack or loss of will power, dependent 
upon cerebral degeneration, probably in the sensory 
zone of the cortical substance posterior to the central 
convolutions. 

Such wanderings of the sexual taste may, and do, 
no doubt, eminate, or, at least, are intensified by evil 
association and immoral practices. 

Sadism 

Is a form of sexual perversion exhibited in the neuro- 
pathic constitution whose psychomotor centre is ever 
on the alert. Sexual desire so stimulates the animal 
or savage part of such characters as to call for atrocity 
and lust that cannot be restrained. It is this form of 
insanity that is responsible for those fiendish crimes of 
which we occasionally hear. To this class, no doubt, 
belongs '^Jack, the Ripper." This insanity is largely 
confined to males. 

Masochism. 

Again, the subject may display the very opposite 
inclination. With the sexual desire there may be 
intimately associated a dominating passion for receiv- 
ing or suffering punishment. This form of perversion 
is displayed by females, as a rule. 

Homosexuality. 

A very common form of perversion, and one that 
expresses itself in several ways, is homosexuality. 
The victims of this alienation find sexual gratification 
in certain indulgences practiced upon their own sex. 
In some instances there is some desire for the oppo- 
site gender, which, however, is eclipsed by the unnat- 
ural and stronger dictate. 



296 GENITO-URINARY SURGERY AND VENEREAI. DISEASES. 

To this class belong the unfortunate degenerates 
whose every act, impulse and desire simulates the op- 
posite sex. A male, thus afflicted will have the gait, 
the manner and disposition of a female ; he will show 
effeminacy in his every movement. His behavior 
toward the male, when circumstances are suitable, will 
be in line with the conduct of a passionate male in the 
presence of a female. 

Such a pervert displays remarkable cunning. A 
morbid instinct teaches him to study character. He 
will mark his victims, so to speak, and so appeal to 
their sexuals that his advances will be tolerated. They 
may even go to the extreme, clothe themselves as 
women, appear upon the streets and solicit men in. a 
way little different from the harlot. They will court 
the favors and intimacy of males with presents and 
attention, and will make personal sacrifices that their 
appetites may be gratified. In this extreme display of 
the psy co-sexual, there is disgust for sexual relations 
with the opposite gender. 

This perversion may take the nature of psederastia or 
sodomy, mutual masturbation or lesbain love. N^ormal 
copulation being impossible and disgusting to them. 

Treatment. 

The influence and power of heredity is great ; the 
mystery of nature's doings is unfathomable — it is proof 
against the comprehension of man. The mightiness 
of environment cannot be denied ; its influence reduces 
character to a single level; through its debasing forces 
strong men fall, and virtue is murdered. 

This most afflicted class of miserable wretches, who 
by their presence pollute the air, curse society and 
poison the earth, should share our pity ; they are by 



NEURASTHENIA SEXUAI.IS. 297 

birth degenerates and by environment degenerated. 
Seldom is treatment sought ; seldom do such perverts 
wish to be different ] they are happy in the gratifica- 
tion of their foremost desire ; they are insane. 

Should such a spirit be displayed by a girl or boy, a 
strict watch should be kept. Such association and 
life should be had that will strengthen the weakness 
of character. Should all moral surroundings fail ; strip 
the character of sex by performing double castra- 
tion in the male and oophrectomy in the female. Such 
work as this must be proposed and executed through 
the aid of witnesses, consultation and with the consent 
of all concerned, otherwise it would be without legal 
consent. With a knowledge of such a defect, most 
positively would I recommend and earnestly perform 
this work. Otherwise the case is to be referred to the 
Alienist or I^eurologist. 

Neurasthenia Sexualis. 

The term neurasthenia implies a debilitated or ex- 
hausted condition of the nerves, though modern usage 
lends it a much broader significance. Sexual neuras- 
thenia might be more aptly put sexual hypochondriasis, 
for the condition as it usually offers is more strictly 
of the latter type, though frequently the neurasthenia 
is responsible for the hypochondria. The condition 
here treated is to be separated from those posterior 
neuroses ; it is that condition where no cause can be 
demonstrated. 

It matters little which name be given, for under 
either comes a class of sufferers, the extent of which 
but few seem to appreciate. 

Prior to and immediately following the period of 
nubility, young men become much concerned about 



298 GENITO-URINARY SURGERY AND VENEREAL DISEASES. 

their sexual appointments ; they become possessed of 
strange and extreme fancies ; they devote themselves 
nnduly to the consideration of this part. The exercise 
of these cerebral areas to the exclusion of others, 
at first results in over-development or undue acute- 
ness, at the expense of all the others. They grow at- 
tentive to all that relates to such matters ; they are 
restrained by the civilizing and refining influence of 
society and modesty ; they bear their real or fancied 
burdens, looking for relief that does not come ; ex- 
haustion of the overtaxed centre results, and they 
grow despondent ; they brood over their misfortunes ; 
their hopes become blighted, and a gloomy pictui'e is 
spread before them. 

Such a patient will be indifferent ; he will shun 
amusement, avoid society and will deny his life all 
sunshine. 

The cause for such a condition comes from the de- 
moralization of his sexual tone, and this through mas- 
turbation, lascivious desires, venereal excess and 
ungratified longings. Occasionally posterior urethral 
disease and other genital defects are responsible. 

Failure to satisfactorily perform copulation, on ac- 
count of precipitate ejaculation, may begin to worry 
him, and loss of confidence follows. 

Diagnosis. 

In the absence of any discoverable disease, a patient 
may be considered a sexual neurasthenic when his de- 
lusions are in line with the above. 

Treatment. 

The quack most often has had possession of him, and 
it is well to hear his story in full ; study his weakness 
and his worth, summon all your tact and resources, 



NEURASTHENIA, SEXUAI^IS. 299 

guard yourself against his interrogations, maintain 
your dignity, be firm, for it is not always the weak- 
minded and illiterate to be advised. When you have 
estimated your patient, you are either to treat his de- 
lusion, or appeal to his intelligence and manhood. If 
he be a man of understanding and reason, you may deal 
plainly with him ; make him understand his real con- 
dition, prove to him that he is laboring under an ex- 
aggerated or erroneous impression, point out his error 
and you will succeed. He will be a candidate for 
tonics, sedatives, alteratives, etc., which may be pre- 
scribed, which, with a change of scene and association, 
cheerful surroundings, electricity, baths and frictions, 
will soon bring about happy ends. 

Should he be a mere boy or an uninformed adult, 
one not capable of interpreting or appreciating the open 
methods advocated above, it is far more satisfactory to 
so encourage and impress him little by little, build him 
up physically, mentally and morally, making the treat- 
ment all the while accomplish specific and decided ob- 
jects, w^hich can always be done by suggestion. Turn 
his thoughts and attentions in proper channels, sug- 
gest a time when he will be well, and subdivide this in 
a way that certain changes or improvements will occur 
at certain periods of treatment, and you will never fail, 
for such sufferers are always impressionable. When 
you have their confidence you can control almost every 
thought. Should such a patient apply, I should pur- 
sue somewhat this order : First, be sure there is no 
deep urethral or other disease. This knowledge can 
only be had from a searching and painstaking exami- 
nation, including a microscopic and chemic inspection 
of his urine. Being satisfied with the diagnosis, and 
after mature deliberation, say that he will be well in 



300 GENITO-URINARY SURGERY AND VENEREAI. DISEASES. 

thirty-six and one-half days ; impress him with this, 
and have him understand that it will be impossible for 
him to do otherwise. 

Prescribe for him in a most mysterious way, give 
him at least two prescriptions, and have the directions 
so complicated that he will have no time to think of 
himself. For instance, prescribe Exs. 77 and 78, 

No. 77. No. 78. 

Bl:.— Potass, brom 5ii. R..— Fl. ex. sennsB- ) ^. 

Tr. hyoscyam \ ^ Syr. aurant eort.... \ ^ ' 

Tr. cann. ind P^ ^ss. rp^.^ ^^^ ^^^ ^.gg_ 

Elix. valerinate am- M. 

mon Biv- S. — A teaspoonful in uine 

M. ft. sol. teaspoonfuls of water twenty - 

S. — A teaspoonful in six two minutes after 8 a. m., 

teaspoonfuls of water three 2 p. m. and 8 p. m. Put into 

minutes after each odd hour. a white bottle. 
Put into a blue bottle. 

and direct that he should carry the white bottle in his left 
pocket for two days and the other in his right, then 
change ; that the medicine from the blue bottle should 
be taken, a teaspoonful in six teaspoonfuls of water 
three minutes after the odd hour up to 9 p. m., at which 
time he should take a glass of milk and retire, when he 
will be asleep in twenty-one minutes, because 7x3 rep- 
resents the number of teaspoonfuls multiplied by the 
number of minutes after the odd hour. The second pre- 
scription may be used in some such manner. The sug- 
gestions should be in line with the action of the 
remedies. If a cathartic be given at night, the patient 
should be advised that his bowels will act freely in 
the morning, etc. 

It is the treatment of this class of ills that such 
brilliant achievements are accorded. Homoeopathy, 
Christian Science, Osteopathy and those forms of treat- 
ment that deal with the imagination. 



THE SEXUAL IMPUIvSE. 301 

Patients permitted to go unrelieved of such delusions 
will eventually become ill, and it is not a matter of 
debate, nor is it derogatory to professional dignity to 
cure such a defect in this manner. That plan of treat- 
ment best suited to the individual should be adopted. 

When the patient has been relieved and the terms of 
treatment fully met, it is important that the patient 
be advised against doctors, medicine and all matters 
that relate to such. 

I do not know that I have failed to relieve a single 
case of this kind. I do know that many very miserable 
individuals have been set right, have married and have 
continued a happy life. 

Thirty days is all the time required. Sexual and 
urethral hygiene is imperative, recreation, outdoor 
physical exercise, sponging, regular hours, good food, 
cheerful surroundings, all promote a favorable in- 
fluence. 

The Sexual Impulse. 

In the human male, as in all animal life, there is a de- 
sire to propagate and to fill the earth with species of its 
kind, or to continue the race through offspring from gen- 
eration to generation. 

That such desire is displayed by nature for a wise and 
good purpose, there are abundant reasons for belief. Na- 
ture, in her generosity toward man, has placed this desire 
first ; it is above all others ; through it the real objects of life 
come; our greatest joys, satisfaction and success is meas- 
ured by it ; it is the foundation of manhood, individuality 
and character. All else is secondary and transient, as 
compared with it. 

The history of man, the study of his disposition and 
desires, from ages past to the present day, is one con- 
nected thought in this department ; cycles with civilizing 



302 GENITO-URINARY SURGERY AND VENEREAI. DISEASKS. 

influences have modified his ideas and manners in many 
important matters, and while he to-day but little resem- 
bles his forefathers in many ways, yet the passion of lust 
burns on with original fervence. Understanding of the 
sexual impulse is information that many seek ; it is knowl- 
edge that should be dispensed generously. What consti- 
tutes normal sexual desire — how is man to interpret it, or 
distinguish it from the pseudo desire f How shall he 
know when it is well to copulate and when it is injurious? 
It would be a privilege to give extended mention of these 
views, but space will not permit. I will, however, briefly 
intimate that the sexual desire in man is governed by as 
natural laws as are the desires for food, drink, rest, exer- 
cise, etc.; that the discharge of the spermatic fluid is as 
essential as the disposal of the accumulated product of 
any other materials that are stored away and no longer 
serve the purposes of the economy ; that in the exercise 
of the genital functions there are natural impulses dictat- 
ing, as strong as in the other features of physiologic law ; 
that the interval between the acts of copulation are as 
variable and as well defined as in any other department, 
and the reason why we are unable to advise specifically is 
for want of knowledge in this the most important part of 
our duty. Should a man ask how often he should eat, or 
should we undertake to advise him in this, we would first 
make inquiry regarding his gastric condition and his 
health generally ; we would learn the character and vol- 
ume of his work, his hours of rest and recreation, the 
climate, clothing and food that is at his disposal, etc. 
From our understanding of physiology generally and the 
science of dietetics, we are able to prescribe correctly and 
have him interpret nature's call for food. Through this 
knowledge he may be able to distinguish between the 
natural and the false. The call for food should not be 



SEXUAL INFELICITY. 303 

made through the sight, smell or picture of such, but 
should come from the digestive apparatus ; one whose ap- 
petite is created in any other manner will not only fail to 
gratify nature, but will do himself an injury by obeying 
an improper dictate. This thought has application to all 
other purely physiologic or animal demands. 

In the brain there is an inhibitory genital. center, in the 
lumbar cord there is a reflex center, and within the con- 
fines of the genital region proper there is a local center. 
The sensation that is dictated by animal need is the sen- 
sation or nerve-awakening incident to stimulation when 
the vesiculge seminales become hlled ; the spinal center is 
then communicated with and the message is forwarded to 
the head center; if the impulse is genuine, the three act 
in concert. 

When copulation is indulged in under this dictate there 
is no exhaustion, no depression and no tax upon the 
vitality. 

Sexual Infelicity. 

Much satisfaction comes through the understanding of 
sexual need with normal gratification, and our greatest 
disappointments follow abuse or misinterpretation of 
these appointments ; the sorest wounds that afflict society, 
domestic strife and unhappiness, are measured by such a 
state. Unfortunate, no doubt, but nevertheless true, that 
love has its most substantial foundation and constant 
abiding place in those unions where gender finds mutual 
content ; there is no incompatibility of temperament, no 
discontent where man and wife have adapted themselves 
to each other, where each has been reared in strict accord 
with natural and correct teaching ; when they have exhib- 
ited through birth and environment a proper evolution 
and development of moral and sexual strength, here they 
find their greatest pleasures, each in the other, and in the 



304 GKNITO-URINARY SURGERY AND VE;NERE;AI, DISEASES. 

aifairs of mutual concern. It is here that sexual enjoy- 
ment is complete, either receiving that full gratification 
of nature's wants; it is this that makes a perfect husband 
and father, attentive to the pleasures, and watchful of 
the interest of his household ; it is this that compensates 
the wife for the performance of all her functions, contents 
her with her portion and develops the maternal instinct. 
Such a state is sexual felicity. 

On account of lax or improper training ; when physical 
development has advanced, while moral and sexual nature 
has gone astray, such characters are restless, mismated 
and unhappy, and their seed will inherit their defects. 
Much may be done to make good these differences and 
bring sunshine into the gloomy household. The sexual 
organs require civilizing, the nervous system demands 
regulation, the parts should be examined and all defects 
cured, as recommended in the several previous chapters. 

Precipitate Ejaculation. 

Much complaint is made (especially by young men) on 
account of precipitate ejaculation. I would be pleased to 
have it that unmarried men know nothing of ejaculation. 
At a tender age they, nevertheless, begin the exercise of 
their genitals, and soon grow to believe that copulation, 
once or oftener each week, is a part of their existence, 
and apply for correction of the hurried discharge. 

Under existing circumstances their irregularities are most 
natural. These young men have been masturbators ; they 
have been patrons of vice and immorality in their many 
forms ; they have abused and demoralized their sexual or- 
ganizations, courted and suffered venereal disease; 
they have developed a desire for novelties, and now 
wonder why it is their sexual appointments are not nor- 
mal. Their association, amusement and life is opposed 



PRECIPITATE EJACUI,ATION, THE METHODS OF THE QUACK. 305 

to sexual rest and vigor, of which they seem to be igno- 
rant. While I now write, such a case applies. This young 
man, age twenty-two, presents a history in line with the 
above. He indulges his sexual appetite three or four 
times a week, rarely with the same character twice. He 
is nervous, excitable, intemperate, irregular in his habits. 
Sexual relations are attended with undue excitement. He 
has had gonorrhoea four times, and I find his deep urethra 
extremely tender. I shall endeavor to apply sexual hy- 
giene. I have applied a weak solution of nitrate of silver 
to his prostatic urethra. I will use a clod sound every 
third day and endeavor to overcome the hypersesthesia of 
this part. 

No. 79. No. 80. 

R. — Sulph. hyocyamine gr. i. I^. — Potass, brom '^ir. 

Camph. mono, brom ^i. M. ft. chart No. YI. 

Sulph. strych gr. i- S. One in a wineglassful 

Aloin gr. v. of water at bedtime. 

Quininse sul 5i' 

M. ft. pil. No. LX. 
' S. One four times a day. 

I have given him these prescriptions and have shown 
him the error of his conduct. In brief, this is the treat- 
ment for such a state. Arsenauro is an excellent tonic; 
iron, quinine and strychnine, syr. lactophosphate of lime, 
may be used with benefit. 

The Methods of the Quack. 

The time once was when this form of industry was con- 
fined to the large cities, and the number of flagrant 
mountebanks could be counted upon the fingers. At this 
time their methods were without system and could be 
readily comprehended. The perpetrators of such fraud 
made little pretension in the direction of respectability. 

Times have changed. The charlatan of to-day is 
clearly the Napoleon of fraud. He is found in every sec- 



306 GENITO-URINARY SURGERY AND VENEREAI. DISEASES. 

tion of the country, under the mantle of religion, in the 
garb of a philanthropist, and in the interest of science. 
His methods are plausible, cunning and far-reaching. He 
has studied the weakness of human nature and learned its 
vulnerable point to be through the sexual. He has mas- 
tered the science of finance by learning all approaches to 
the purse and bank account. In a word, he is the 
shrewdest and most seductive specimen of all impostors. 
He is worse than a vultuke, or shark. He is, indeed, the 
human octopus, for, through his cunning, he winds his 
tentacles firmly about his trusting victim, fastens his 
suckers upon his vitals, and begins his slow, unceasing 
and merciless consumption of his prey. 

Within the past six years I have devoted some study 
to their methods. I have corresponded with almost a 
hundred, and have personally consulted about a dozen. 
They secure the names and addresses of all the young 
men in the land. This is done through agencies that 
make a business of keeping this directory up to date. 
They have learned that literature mailed for the first time 
will bring about eight per cent, of responses; that a dif- 
ferent class of literature mailed to the same addresses will 
develop about five per cent, of replies; the third lot will 
induce a certain number to make inquiry. A young 
man, receiving such advertising, may throw it aside with- 
out looking it over. In a few weeks he is sent a second 
supply, that he will read at his leisure through curiosity, 
and this may, in turn, be thrown away. Soon, a third 
assortment is at hand that he will read with more inter- 
est. This he will carry about him for future reference. 
He begins to think about what he has read. It has been 
suggested that he may have masturbated during his early 
manhood or suffered from nocturnal emissions, that his 
memory for names and dates may be weakened, that he 



THE METHODS OF THE) QUACK. 307 

may be passing seminal fluid with his stool or with his 
nrine, that there may be aversion to ladies' society, 
pimples on the face, shortness of breath from violent ex- 
ercise, palpitation of the heart from running upstairs, a 
full feeling after a hearty meal, a tired and sleepy sensa- 
tion in the afternoon, dark or floating spots in the field of 
vision, a viscid discharge after erection, that the penis 
may be small, cold and pale, that the scrotum may hang 
low in warm weather, and much else of this nature. 

They will suggest that the urine be passed in a glass 
and let stand for twenty-four hours. '^If there is a deposit 
it is seminal fluid," and every symptom suggested will ap- 
pear when the unfortunate finds this (purely normal floc- 
culent deposit). Then it is that the unfortunate fills out 
the symptom blank and enters negotiations with this 
v^onderful and good man, Dr. Quack. Should he hesi- 
tate about the terms, a special reduction is made him, or 
he is given a free trial outfit. The correspondence that 
follows is stereotyped and elegant in composition. Sev- 
eral times I have written under three distinct addresses, 
and described three widely different conditions, and the 
several responses would be identical. 

The daily press, religious publications and periodicals of 
all kinds, receive their advertisements. The headings are 
attractive to certain classes. Lost manhood, prematuee 

DECAY, EARLY Or YOUTHFUL INDISCEETIONS, PREMATURE 

DISCHARGES, SEMINAL WEAKNESS, ctc, are headings dis- 
played in bold type. 

The words ''free'' and "guaranteed" are almost invari- 
ably parts of such announcements, unsolicited testi- 
monials, especially from the clergy, are conspicuous 
arguments. Many concerns engaged in this irregular 
business are incorporated with capital stock reaching the 
hundred thousands, and with corporate name that im- 
plies a state concern. Bank references are freely given. 



308 GENITO-URINARY SURGERY AND VENEREAI. DISEASES. 

When a young man becomes delinquent, or should he 
be slow to advance the price of additional treatment^ their 
letters grow stronger, 'imploring the patient to continue 
treatment before it is too late." They picture the deepest 
despair awaiting him, and may suggest that delay means 
insanity. Some even go so far and threaten to advise the 
parents or guardians of the deplorable condition of the 
patient, except he continue treatment. 

With the average young man it is exceedingly difficult 
to resist their methods, and when once their victim it is 
all but impossible to dispose of them. As physicians it 
is clearly our duty to shield the ignorant, susceptible and 
weak against the approach of this class. Very much ill- 
ness, real and fancied, has its origin here, and this sub- 
ject is given space that the family physician may know 
the origin of this suffering and meet it with under- 
standing. 



INDEX 



_^BSCESS of 

Cowper's glands, 112. 
lymphatics, 109. 
prostate, 145. 
urethral follicles, 110. 
Adenitis, 

chancroidal, 169. 

gonorrhoeal, 109. 
Albumen, tests for, 245. 
Amputation of penis, 55. 
Anatomy of 

bladder, 24. 

epididymis, 20. 

kidneys, 27. 

penis, 9. 

seminal vesicles, 19. 

testicles, 22. 

urethra, 15. 

ureters, 26. 

vasa deferentia, 19. 
Anomalies of the penis, 34. 
Arduor urinse, 89. 
Atony of bladder, 162. 
Atrophy- of 

prostate, 150. 

testicles, 270. 
Atresia of the urethra, 59. 



JgACILLUS in chancroid, 166. 

Balanitis, 46. 
Bigelow's evacuator, 224. 

lithotrite, 223. 

tubes, 224. 
Bistoury, Gouley's, 211. 
Bladder, 

anatomy of, 24. 

atony of, 154-162. 

bar at neck of, 153. 

chorea of, 234. 

catarrh of, 129. 

exstrophy of, 48. 

foreign bodies in, 214. 

hypertrophy of, 154. 

inflammation of, 129. 

paralysis of, 236. 

puncture of, 236. 

stone in, 214. 

tumors of, 233. 



Bougie a boule, 194. 

filiform, 195. 

olivary, 158. 
Bubo, chancroidal, 169. 

gonorrhoeal, 109. 
Buck's fascia, 13. 
Bulb of the urethra, 16. 
Bull-headed clap, 108. 

rjAIvCIFICATION of the penis, 47. 

Calculi, 
prostatic, 149. 
renal, 180. 
urethral, 214. 
vesical, 214. 
Cancer of the 

kidneys, 179. 

penis, 38. 

prostate, 149. 

scrotum, 38. 

testes, 271. 
Castration, 272. 
Catarrh of the bladder, 

acute, 129. 

chronic, 132. 
Catheters, Gross', 159. 

Mercier's, 158. 

Nelaton's, 156. 

staff, Mason's, 208. 

tunnelled, 195. 
Catheterization, 60. 
Chancre, differential diagnosis, 43. 
Chancroid, definition, 166. 

auto-inoculability, 167. 

bubo from, 169. 

complications of, 169. 

course of, 169. 

differential diagnosis, 43. 

element in, 166. 

incubation of, 166. 

frequency of, 167. 

phagedenic, 169. 

prognosis in, 170. 

treatment of, 170. 
Chordee, 88. 
Chorea of bladder, 234. 
Circumcision, 

history of, 48. 

advantages of, 48. 

operation, 49. 



310 



INDKX. 



Colic, renal, 176. 
Concretions, prostatic, 149. 
Congestion of prostate, 142. 
Conjunctivitis, gonorrhceal, 134. 

diagnosis, 135. 

prognosis, 136. 

symptoms, 135. 

treatment, 136. 
Copaiba, balsam, 100. 
Cord, spermatic, 22, 
Corpora cavernosa, 11. 
Corpus spongiosum, 11. 
Cowper's glands, 16. 

inflammation of, 112. 
Cryptorchidism, 267. 
Cubebs, 100. 
Cupped sound, 99. 
Curve of urethra, 59. 

urethral instruments, 59. 
Cutaneous affections, 38. 
Cysts of the testicle, 265. 
Cystitis, acute, 129. 

chronic, 132. 

causes of, 130. 

diagnosis, 131. 

prognosis, 130. 

treatment, 132. 
Cystoscope, 219. 

DEFERENTITIS, 129. 

Deformities of the penis, 34. 

bladder, 48. 

urethra, 47. 
Dermoid cysts, 265. 
Dilator, Gouley's, 201. 
Director, Arnott's, 211. 
Dislocation of the penis, 37. 
Divulsion of stricture, 201. 
Dropsy of the genitals, 249. 

J]CZEMA of the genitals, 38. 

Ejaculatory ducts, 17. 
Elephantiasis, 38. 
Electrolysis in stricture, 202. 
Electroscope, Leiter's, 77. 
Emissions, seminal, 

diurnal, 290. 

nocturnal, 290. 

treatment, 291. 
Endoscope, Koltz's, 76. 

Otis', 76. 
Endoscopy, 76. 
Epididymis, 20. 
Epididymitis, 

causes, 115. 

diagnosis, 120. 

prognosis, 119. 

treatment, 120. 



Epididym-orchitis, 128. 
Epiplocele, 23. 
Epispadias, 47. 
Epithelioma of penis, 38. 

differential diagnosis, 43. 

treatment, 39. 
Erection of penis, 274. 
Erythema, copaibal, 100. 
Exstrophy of the bladder, 48. 
Extravasation of urine, 192. 

JpALSE passage, 202. 

stricture, 16, 183. 
Fascia, Buck's, 13. 
Fever, urinary, 69. 
Fistula, urethral, 111. 
Folliculitis, 110. 
Foreign bodies in the bladder, 73, 214. 

urethra, 73. 
Fossa navicularis, 15. 
Fracture of the penis, 36. 

(3J-ALVANISM in stricture of the 

urethra, 202. 
Genital organs, 9. 
Glands, Cowper's, 16. 
Gland, prostate, 18. 
Glands of Tyson, 13. 
Glands, urethral, 15. 
Glans-penis, 11. 
Gleet, 103. _ 
Globus major, 20. 
Globus minor, 20. 
Gonococcus of Neisser, 83. 
Gonorrhoea, 82. 

bastard, 81. 

complications of, 107. 

course, 88. 

diagnosis, 86. 

importance of, 85. 

incubation, 88. 

pathology, 87. 

posterior, 89. 

prognosis, 89. 

relapsing, 105. 

stages of, 88. 

symptoms of, 88. 

treatment, 90. 
Gonorrhceal conjunctivitis, 134. 

rheumatism, 137. 
Gubernaculum testis, 24. 
Gorget, Teal's, 211. 

JJAEMATOCELE, 265. 

Haematuria, 238. 
Hermaphrodism, 64. 
Herpes progenitalis, 41. 

differential diagnosis, 43. 



INDEX. 



311 



Hernia, differentiated, 252. 
Homosexuality, 295. 
Horn's cutaneous, 39. 
Hydatids of Morgagni, 22. 
Hydrocele, causes, 249. 

congenital, 23, 249. 

definition, 249. 

differential diagnosis, 251-2. 

treatment, 252. 

varieties, 249. 
Hydronephrosis, 177. 
Hygiene, urethral and sexual, 72. 
Hypertrophy of the prostate, 151. 

the testes, 270. 
Hypospadias, 47-64. 

TMPERFORATION of the ure- 
thra, 59. 
Impotence, 276. 

atonic, 277. 

diagnosis, 278. 

organic, 276. 

prognosis, 278. 

psychical, 282. 

treatment, 279. 
Incontinence of urine, 234. 
Infiltration of urine, 37, 192, 
Inversion of the sexual fancy, 294. 
Irrigation of bladder, 155. 

urethra, 91. 

JOINTS involved in gonorrhoeal 
rheumatism, 138. 

XBYES' syringe, 99. 

Kidney anatomy, 27-33. 

cancer of, 179. 

colic, 176. 

floating, 181. 

inflammation of, 175. 

parasites in, 175. 

stone in, 180. 

surgery of, 179. 

syphilis of, 182. 

tumors of, 80, 175. 

tuberculosis of , 175. 
Kiefer nozzle, 98. 
Knife, Walker's, 123. 

LACUNA magna, 15. 

Lewis' applicator, 99. • 
Ligament, triangular, 16. 
Litholapaxy, 223. 
lyithotomy, 

advantages of, 225. 

definition, 225. 

instruments, 226-228. 

operation, 225. 



Lithotomy, 

position, 208-226. 

varieties, 229. 
Lithotrity, 223. 
Lithotrite, Bigelow's, 223. 
Lymphangitis, 107. 
Lymphatics of the penis, 15. 

;M;ASTURBATI0N, 285. 

consequences of, 286. 

treatment of, 288. 
Masochism, 295. 
Meatus urinarius, 13. 
Meatoscope, 90. 
Meatometer, 196. 
Mediastinum testes, 23. 
Membranous urethra, 16. 
Methods of the quack, 305. 
Monorchidism, 269. 

]S^EISSER, gonococci of, 83. 

Nelaton catheter, 156. 
Nephralgia, 176. 
Nephrectomy, 180. 
Nephro -lithotomy, 180. 
Nephrorraphy, 181. 
Nephrotomy, 179. 
Neuralgia of testes, 266. 
Neurasthenia sexualis, 297. 
Neurosis, post -gonorrhoeal, 107. 
Nymphomania, 294. 

Qh]DEMA of the genitals, 39, 107. 
Orchitis, 125. 
diagnosis, 126. 
prognosis, 126. 
treatment, 127. 
Organs of generation, 9. 
Ossification of the penis, 47. 
Otis, bougie a boule, 194. 
urethrameter, 195. 



PARAPHIMOSIS, 40. 

Passage, false, 202. 
Penis, 

absence of, 35. 

accidents to, 36. 

amputation of, 55. 

anatomy of, 9. 

anomalies of, 34. 

calcification of, 47. 

cancer of, 38-43. 

cutaneous affections of, 38. 

dislocation of, 37. 

fracture of, 36. 

lymphatic affections of, 39, 

ossification of, 47. 



312 



INDKX. 



Penis, 

piij'siology of, 9. 

skin of, 13. 

tumors of, 38. 
Peri- urethritis, 88, 112. 
Per^^ersion of sexual fancy, 294. 
Phagedena, chancroidal, 169. 
Phimosis, 40. 
Pneumaturia, 240. 
Pollutions, 

diurnal, 290. 

nocturnal, 290. 
Posthitis, 46. 

Precipitate ejaculation, 304. 
Prepuce, 14. 
Prostate, 

abscesses of, 142. 

anatomy of, 18. 

atrophy of, 150. 

cancer of, 149. 

physiology of, 18. 

tuberculosis of, 148. 

hypertrophy of, 151. 
complications, 152. 
diagnosis of, 154. 
prognosis, 154. 
treatment, 154. 
Prostatitis, 142. 

follicular, 142. 

parenchymatous, 145. 

treatment, 143. 
Prostatic concretions, 149. 

ducts, 17. 

urethra, 16. 
Prostatorrhcea, 143. 
Pyelitis, 175. 

causes, 175. 

diagnosis, 177. 

treatment, 178. 
Pyonephrosis, 175. 

J^APHE median of penis, 13. 
Retention of urine, 36, 235. 
significance of, 238. 
Rheumatism, gonorrhceal, 137. 

gACCUIvATION of the bladder, 158. 

Saccharometer, 247. 
Sadism, 295. 
Sandal-wood oil, 100. 
Sarcoma of testicle, 271. 
Satyriasis, 294. 
Scale of sounds, 186. 
Scrotum, anatomy of, 21-22. 

resection of, 264. 
Searcher, Thompson's, 218. 
Self abuse, 285. 
Seminal vesicles, 19. 



Sexual felicity, 303. 

impulse, 301. 

infelicity, 303. 
Sinus pocularis, 17. 
Sinuses of Morgagni, 15. 
Sounds, bulbous, 194. 

conical, 194. 

tunnelled, 196. 
Spermatocele, 265. 
Spermatorrhoea, 291. 
Spermatozoa, 268. 
Staff, Mason's catheter, 208. 

Wheelhouse's, 212. 
Sterility, 285. 
Stone in the bladder, 

causes, 214. 

complications, 215. 

diagnosis, 218. 

symptoms, 217. 

treatment, 221. 
Stone in the kidney, 180. 

treatment, 180. 
Stone in the prostate, 149. 

treatment, 150. 
Stone ache, 266. 
Stricture of the urethra, 

causes, 187. 

complications, 191. 

diagnosis, 193. 

definition, 183. 

location, 186. , 

number, 186. 

pathology, 187. 

symptoms, 190. 

time of development, 189. 

treatment, 199. 

varieties, 183-185. 
Strapping the testicle, 123. 
Suppression of the urine, 236-238. 
Suspensory ligament, 13. 
Syphilis of the kidney, 182. 

testicle, 271. 

urethra, 81. 

TESTICLES, absence of, 267. 
anatomy of, 22. 
atrophy of, 270. 
hypertrophy of, 270. 
injuries of, 269. 
inflammation of, 125. 
neuralgia of, 266. 
physiology of, 22. 
removal of, 272. 
syphilis of, 271-272. 
strapping, 123. 
supernumerary, 269. 
tumors of, 265, 271. 
tuberculosis, 271. 
undescended, 267. 



INDEX. 



313 



Testicles, 

wounds of, 269. 
Thompson's device in hypertrophy 

of the prostate, 157. 
Thompson's stone searcher, 218. 
Trigonum vesicae, 25. 
Triangular ligament, 16. 
Tumors of the kidnev, 175. 

bladder, 229. 

penis, 38. 
Tunica albuginea, 22. 

vaginalis, 22. 
Tubercular urethritis, 82. 



XJRACHUS, 24. 

Ureters, anatomy, 26. 
inflammation of, 134, 
wounds of, 134. 
Urethra, anatomy of, 15-18. 

atresia of, 59. 

curve of, 15, 58. 

deformities of, 47-59. 

diseases of, 79. 

examination of, 76. 

exploration of, 60. 

foreign bodies in, 73. 

imperforation of, 59. 

injection, 92. 

injuries of, 36. 

irrigation, 91. 

membranous, 16. 

prostatic, 16. 

spongy, 15. 

stricture of (see stricture) 
Urethral speculum, 77. 

syringes, 92. 
Urethrometer, 195. 
Urethroscope, 78. 
Urethroscopy, 76. 
Urethrotomes, 206. 
Urethrotomy, external, 207. 

internal, 203. 
Urethritis, 79. 
Urinary organs, 9. 



Urination, 

physiologic, 231. 

difficult, 233. 

urgent, 232. 
Urinary fever, 69. 
Urinometer, 242. 
Urine, 

albumen in, 245. 

diabetic, 246. 

examination of, 241. 

extravasation of, ?)'7 , 192. 

high color of, 241. 

incontinence of, 

adults, 235-238. 
infants, 234-238. 
diurnal, 235. 
nocturnal, 234. 

retention of, 36, 235-238. 

suppression, 236-238. 

significance of, 237-241. 
Uvula, vesicae, 26. 

YARICOCELE, 257. 

causes, 258. 

symptoms, 258. 

treatment, 260. 
Vas deferens, 19. 

inflammation of, 129. 
Vegetations, 44. 
Vesicle, seminal, 19. 

inflammation of, 112. 

treatment, 114. 
Veru montanum, 17. 

^ARTS, venereal, 44. 

causes, 44. 

treatment, 45. 
White's scrotal compressor, 124. 
Wounds of the 

penis, 36-38. 

testes, 269. 

urethra, 36. 

ureters, 134. 
Wrappings in gonorrhoea, 102. 



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